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Code Blue Documentation Template

This code blue form documents a medical emergency event involving a patient. It records details of the patient, the circumstances leading up to the code activation, the resuscitation measures performed by the code blue team, and the outcome of the event. Key details included are the patient's name and demographic information, the reason for code activation, timing of the code team's arrival and treatments administered, duration of CPR and defibrillation attempts, medications given, and whether the patient survived or expired after resuscitation efforts concluded. The form is signed by the code blue team members and person documenting the event.

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Raviraj Pishe
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13K views2 pages

Code Blue Documentation Template

This code blue form documents a medical emergency event involving a patient. It records details of the patient, the circumstances leading up to the code activation, the resuscitation measures performed by the code blue team, and the outcome of the event. Key details included are the patient's name and demographic information, the reason for code activation, timing of the code team's arrival and treatments administered, duration of CPR and defibrillation attempts, medications given, and whether the patient survived or expired after resuscitation efforts concluded. The form is signed by the code blue team members and person documenting the event.

Uploaded by

Raviraj Pishe
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Code Blue Form

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:
[Link]. 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
[Link]. Members name Signature

Documented by
Name: Date: Time:
Signature:

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