CODE BLUE FORM

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DATE:TIME:(Military Time) FOUND BY:LOCATION:CONDITION:CPR InitiatedMilitary TIMEIntubationMilitary TIMECentral Line PlacementMilitary TIMEOtherMilitary TIME ( Describe ) > > Epinephrine Bolus Syr. Atropine Bolus Syr. Lidocaine Bolus Syr. Sodium Bicarbonate Bolus Syr. Vasopressin Bolus ( Vial 20 units ) Magnesium Sulfate Bolus Amiodarone Bolus 50mg / ml - 3 ml Dopamine Drip Levophed Drip Neosynephrine Drip Fluid Rhythm / HR B P Defib Time / Joules Pacer / Time / MA Labs / ABGs Sent RECOVERY DEATHMD SIGNATURE:RN SIGNATURE / TITLE:8850447 Rev. 05/05PAGE 1 of 1PART OF THE MEDICAL RECORDPATIENT IDENTIFICATIONCode blue Form_NURSINGS T A R T O F C O D ER E S U S C I T A T I O N E F F O R T SWHITE COPY = Chart YELLOW COPY = ICU Medical Director PINK COPY = PharmacyD R U G STIME / DOSETIME / DOSETIME / DOSETIME / DOSETIME / DOSETIME / DOSED R U G S / F L U I D / R A T ETIME / RATE TIME / RATE TIME / RATE

DATE: TIME: (Military Time) FOUND BY: LOCATION: CONDITION: CPR Initiated Military TIME Intubation Military TIME Central Line Placement …

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