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CPR Checklist

This document is a performance evaluation checklist for cardiopulmonary resuscitation (CPR). It lists 10 key steps for CPR, including checking for safety and responsiveness, calling for help, opening the airway, checking for breathing, performing 30 chest compressions followed by 2 rescue breaths, and repeating cycles until help arrives or the victim starts breathing. Performers are rated on a scale from 0-5 on their ability to complete each step independently or with assistance. The checklist collects the name, date, level, and group to evaluate CPR performance.

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Jenny Agustin Fabros
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9K views2 pages

CPR Checklist

This document is a performance evaluation checklist for cardiopulmonary resuscitation (CPR). It lists 10 key steps for CPR, including checking for safety and responsiveness, calling for help, opening the airway, checking for breathing, performing 30 chest compressions followed by 2 rescue breaths, and repeating cycles until help arrives or the victim starts breathing. Performers are rated on a scale from 0-5 on their ability to complete each step independently or with assistance. The checklist collects the name, date, level, and group to evaluate CPR performance.

Uploaded by

Jenny Agustin Fabros
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
  • CPR Performance Evaluation Checklist: Detailed checklist for evaluating cardiopulmonary resuscitation procedures, including preparation, execution, and post-procedure steps for learners.
  • Evaluation Criteria: Provides the rating scale and grading criteria used to assess CPR performance, with designated scores for varying levels of proficiency.

PERFORMANCE EVALUATION CHECKLIST

Name Date
Level & Block Group

CARDIOPULMONARY RESUSCITATION
Performed
Performed Unable to
with
PROCEDURE Independently Perform Remarks
Assistance
4-5 2-3 0-1
Preparation steps:
1. Check the scene for safety.
2. Check for responsiveness using shout-
tap-shout.
3. If the person does not respond and is
not breathing or only gasping, CALL 911
or EMS or the local emergency number
to get equipment, or tell someone to do
so.
4. Place the person on his/her back and
open the airway.
Place the person carefully on his/her
back and kneel beside the chest. Tilt
his/her head back slightly by lifting the
chin.
5. Open the mouth.
6. Check for breathing. Place your ear next
the person's mouth and listen for no more
than 10 seconds. If you do not hear
breathing, or you only hear occasional
gasps, begin CPR.
CPR Steps
7. Perform 30 chest compressions. Place
one of your hands on top of the other and
clasp them together. With the heel of the
hands and straight elbows, push hard and
fast in the center of the chest, slightly
below the nipples. Push at least 2 inches
deep. Compress their chest at a rate of
least 100 times per minute. Let the chest
rise fully between compressions.
8. Perform two rescue breaths Making sure
their mouth is clear, tilt his/her head back
slightly and lift the chin. Pinch their nose
shut, place your mouth fully over his/hers,
and blow to make the chest rise. If the
chest does not rise with the first breath,
re-tilt the head. If the chest still does not
rise with a second breath, the person
might be choking.
9. Repeat the cycle of 30 chest
compressions and two rescue breaths
until the person starts breathing or help
arrives. If an AED arrives, carry on
performing CPR until the machine is set
up and ready to use.
10. Place the victim in the recovery position if
you must leave to get help, or if fluids or
vomit may block the airway.

Grade:
Rating Scale:

Excellent : 96-100 Good : 80-84


Very Satisfactory : 90-95 Fair : 75-79
Very Good : 85-89 Poor : 74 & below

Clinical Instructor

Signature over Printed Name

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