Mock Code (AMS) Performance Education Summary: Role: RN ( ) PCA ( )
Unit: ____________________
Name: ________________________________________ Kronos # _______________ Date: ____________________
Validation Method: RD=Return Demonstration, Test (W)=Written Test, Test (V)= Verbal Test, DR=Document Review.
Skills Competency w/Performance Criteria Validation M=Met Validator
Method NM=Not Initials
Met
Emergency Response Preparedness
Emergency cart check: confirm presence of back board, bag-mask device, oxygen face Test (V) & M
mask non-rebreather, nasal cannula, oxygen tank, AED, Zoll pads, portable suction RD
machine, extension cord, sealed intubation tray, identify location 1 st item to expire
demonstrates operation of oxygen tank, confirms code ready status of defibrillator, Test (V) & M
performs manual defibrillator check RD
Emergency Response/Crisis Intervention
RRT: Recognise acute changes in psychiatric patient’s condition including alteration in Test (V) & M
mental status, activate RRT, provide emergent care. RD
Code 99: Recognizes when to Code 99. Activates emergency response (call out and
dial 1111) Performs adult CPR and AED per AHA skills checklist
Post Emergency Response
Cart exchange: returns used equipment in Red plastic bags to CSD, performs low level Test (V) & M
disinfection of monitor/defibrillator, coordinates cart exchange with CSD RD
Documentation and Debriefing: documents code activity on Cardiopulmonary Arrest/ Test (V) & M
Resuscitation Flowsheet and scans into patient’s EMR. Participates in code team DR
debriefing led by nursing supervisor.
Remediation Plan with time frame for completion for competencies not met:
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Validator Initials:
Participant Signature: _________________________________________________________
4/19/2018 PDD
