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Code Blue Evaluation Form

The document is a code blue evaluation form for a hospital that collects information about code blue incidents including the date, patient details, treatment provided, and outcome. It requests information like the time of the code blue call and arrival, the names of staff involved, any medications or defibrillation used, and the total time of resuscitation efforts.

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Jay Gohil
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101 views2 pages

Code Blue Evaluation Form

The document is a code blue evaluation form for a hospital that collects information about code blue incidents including the date, patient details, treatment provided, and outcome. It requests information like the time of the code blue call and arrival, the names of staff involved, any medications or defibrillation used, and the total time of resuscitation efforts.

Uploaded by

Jay Gohil
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Bombay Maternity and Surgical Hospital -Surat Revision: 0

Code Blue Evaluation Form – COP/19/01 Date:

Code Blue Evaluation Form


(To be filled up by House Officer / Nurse attending code blue)

• Date: _____________________ IP No. ______________________

• Name of the Patient: _____________________________________

• Patient Care Unit: _______________________________________

• Diagnosis of the patient: _________________________________

• Name of House Officer/Unit In-Charge: ______________________

• Employee who called Reception for Code Blue : ________________

• Name of the Employee at Reception

(Who received the Call) :- __________________

• Time of Calling the reception for the Code Blue :- __________________

• Time of Announcing the Code Blue :- __________________

• Time of Arrival of the Code Blue Team :- __________________

• Name of Team Leader :- __________________

• Intubation Time (If done) : __________________________

• Defibrillator : _____________________________________

(If used how many shocks and Joule)

• Medication : ______________________________________

(If given which and how much)

• Total time of giving resuscitation :_____________________

• Outcome of the Patient :_____________________________


Bombay Maternity and Surgical Hospital -Surat Revision: 0

Code Blue Evaluation Form – COP/19/01 Date:

• Any Remarks : ____________________________________

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