Transcription of CODE BLUE FORM - World's Largest Public …
1 DATE:TIME:(Military Time) FOUND BY:LOCATION:CONDITION:CPR InitiatedMilitary TIMEI ntubationMilitary TIMEC entral Line PlacementMilitary TIMEO therMilitary 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.
2 05/05 PAGE 1 of 1 PART 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 TIME / RATE TIMETIMEI . V . / F L U I D / R A T EI N T E R V E N T I O N STIMETIMETIME / RATE TIME / RATETIMETIMER E S U S C I T A T I O N O U T C O M EMD IN CHARGE:FOR INTUBATIONAPNEICONLYPULSELESSOTHER: _____STOPPED: _____TIME BP: _____HR: _____RR: _____RHYTHM: _____RECEIVING UNIT: TIME OF DEATH: _____PMD NOTIFIED BY: _____CODE blue form