CARDIAC ARREST FORM

CARDIAC RESCUCITATION RECORD ESTIMATION DURATION OF ARREST :

DATE: PRIOR TO CPR: ( ) < 1 MIN ( ) 1-4 MIN ( ) 4-6 MIN ( ) 6 MIN ( ) UNKNOWN
ARREST LOCATION: CPR STARTED BY:
WITNESSED: ( ) YES ( ) NO TUBE SIZE: STICKER
PRE-ARREST DIAGNOSIS :
I.V. STARTED BY:
RUMAH SAKIT UNIV. AIRLANGGA
Jl. Mulyorejo Kampus C Unair
TIME PERSONAL IN ATTENDANCE:
RHYTHM 1
VITAL SIGNS

PULSE 2
BP 3
RESP 4
5
PHYSICIAN IN CHARGE:
MEDICATION

RESCUCITATION STOPPED:
AT:
BY:

FAMILY NOTIFIED: ( ) YES ( ) NO

ATTENDING PHYSICIAN NOTIFIED: ( ) YES ( ) NO

DEFIBRILATION (JOULES) TRANSFER TO:

PROCEDURES

CONDITION:

NURSING NOTES:

PH
PO2
PCO2 SIGNATURE:
BGA

HCO3 (dr………………………………………….)
SaO2
BE (Ns………………………………………)