KINGDOM OF SAUDI ARABIA

MINISTRY OF HEALTH
JAZAN HEALTH
PRINCE MOHD BIN NASSER HOSPITAL

RAPID RESPONSE TEAM FORM

Name of Patient: MRN: Nationality:
Age & Sex: / Department: Bed # Consultant Name:

Caller:_______________________ Date:__________ Time Called: ________ Arrival Time: _______ Time Event Ended:_______

(S) Situation: RAPID RESPONSE TEAM INTERVENTIONS:

Staff concerned/ worried AIRWAY/ BREATHING CIRCULATION
Specify: Oral Airway IV Fluid Bolus
________________________________________________ Suctioned Blood
Nebulizer treatment ECG
HR less than 40 HR greater than 130 Intubated CPR
SBP less than 90 mmHg Acute mental status change NPPV Defibrillation
RR less than 8 RR greater than 24 Bag Mask Cardioversion
SpO2 less than 90% FiO2 50% or greater O2 mask/ nasal No intervention
Acute significant bleed Seizures ABG
Change in Urine Output to <50 ml in 4 hours CXR
(B)Background No intervention
Other interventions:
Admitting Diagnosis: ________________________________________ _________________________________________________
_________________________________________________
Possible contributing factor/s to present situation:
_________________________________________________
Current medication: ____________________________________ _________________________________________________
Allergy status:__________________________________________ Medication(s):
Lab results: ____________________________________________ Dose Route
Name Frequency
Latest procedure/ treatment: _____________________________
_______________________________________________________
Others, specify __________________________________________
_______________________________________________________
_______________________________________________________

(A)Assessment
BP ___________ HR______ RR______ Temp_______ SpO2 _______
The problem seems to be _________________________________
__________________________________________________________________
___________________________________________________________
(R) Recommendation
Treatment _____________________________________________
Tests __________________________________________________
Other, specify __________________________________________
_______________________________________________________
_______________________________________________________
Notify Treating Physician: ________________ Time: _________
Notifying Staff: ____________________________________________
Stamp & Signature
Outcome:
Stayed in room Transferred to HDU
Transferred to ICU
Other, specify_____________________________________________
_____________________________________________
Rapid Response Team (RRT) Recommendations:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
RRT Leader: __________________________________________
Team Stamp &Signature:
Members:________________________________________
_____________________________________________
_____________________________________________

Date: ____/____/_____Time: _________ Date: ____/____/_____Time: _________

QPS