Code Blue Form

Type of event Actual Event Mock Drill Date ___________

Patient Details:
Name: __________________________________ UID ______________________
Age ____________ Gender ________ Ward / Unit _________________________
Diagnosis (Pre-arrest) ________________________________________________
Any Pre-arrest intervention ____________________________________________
Code Activation:
Code activated by _____________________________ Designation__________
Time of code activation ______________
Condition at the time of code activation:
Unresponsive Apnoea No Pulse Gasping

Other __________________________________________________________
Time of code team arrival: 1st member __________ 2nd member ____________
Name of code blue team leader_______________ arrival time ______________
Resuscitation measures
Duration for which CPR given __________________
Intubation given? Yes/No, If Yes, then time _______
Central line given? Yes/No, If Yes, then time _______
Defibrillator used? Yes/No, If Yes, then time and duration ___________
List of medicine administered:
S.No. Medication Dose Remark

Other measures:

Outcome
Outcome of resuscitation: Patient survived Patient Expired
Time at which resuscitation efforts stopped:
Vitals at stopping: HR____ BP _______ SPO2 ______Rhythm ________
Patient shifted ICU: Yes/No If not, location of patient ________________
Post resuscitation advice: ______________________________________
_______________________________________________________________
Code blue team members and signatures
S.No. Members name Signature

Documented by
Name: Date: Time:
Signature: