MRN:_________________________

NAME :_________________________________
NATIONALITY:_________________________
GENDER : ____________________________
ID / IQAMA : _______________________

RAPID RESPONSE TEAM REPORT

DATE OF ADMISSION: ___________ RRT ACTIVATION

DAIGNOSIS: 1. __________________
2. __________________ DATE:________________
3. ___________________ TIME ; _________________

REASON FOR RRT ACTIVATION : ________________________________________

VITAL SING :
BP : __________ PULSE : _______________ TEMP : ___________________ O2 SATURATION :___________

Indication For Response Team: ( NB : please fill This part accordingly )

RESPIRATORY STAUS: DISTREES YES NO CYANOSIS YES NO APNEA YES NO
CARDIAC STATUS: TACHYCARDIA YES NO
NEUROLOGICAL STATUS: CONSCIOUS: YSE NO OTHERS : __________
CHEST PAIN: YES NO OTHERS / SPECIFY _____________
STAFF / FAMILY CONCERNS: YES NO SPECIFY :_____________

INTERVENTIONS : MEDICATION :
1.__________________ 1.____________
2.__________________ 2._____________
3______________________ 3.______________
REPORT BY :
4._______________________ 4 .________________

PATIENT OUTCOME :

STABLE TRANSFERRED TO ICU CODE BLUE ACTIVATED CONSULTATION

SN TEAM MEMBER NAME TIME ARRIVED ROLE

1
2
3
4
5
6
7
CONFIRMED BY :

WARD NURSE Nurse Supervisor ICU PHYSICAN ICU NURSE

----------------- -------------------- ----------------------- ---------------------

Responsible Physician

BDGH 028/1440