Page Date

of

Type of Arrest: CPR Started

Time of Arrival in ED N/A Cardiac

Time & Location of Arrest

Hx of Event

EMS Hospital Staff Wt.

Initial VS

BP

Respiratory Witnessed ALS Started EMS Bystander T P R

Unwitnessed

Procedures Performed
Artificial Ventilation: Bag/Mask Intubated: Oral Time Nasal Cric Size Trach Bag/Endo Tube By No. Attempts Placement Confirmed By By Medications (* if given by ET Tube) EPI 1:10,000 Lidocaine Atropine Intraosseous: Venipuncture: Venipuncture: Foley Cath: Rhythm Response Dopamine Lidocaine Time Time Time Size & Site Size & Site Size & Site Time Size ABG Drawn () By By By No. Attempts

Attempts No.

Tube Secured At (cm) NG/OG Tube: Time Size Defib. Joules

Central Venous Catheter: Time IV Meds/Fluids IV Fluid Bolus

Size & Site

Attempts No. By
By

1:1,000EPI

Was the patient successfully resuscitated? Time code terminated Family notified Names of all individuals present at code:

Yes

No

Patient expired at Attending called

Pronounced by

PATIENT IDENTIFICATION

Disposition of Patient: Time

Location

R.N. Signature

Physician Signature/Arrest Order Verification

Cardiopulmonary Resuscitation Flow Sheet

N5516 Rev. (12/31/2003)

Nurses Notes (pO2, pCO2, pH, Color, Mental Status, Temp., Pupils, Procedures, etc.)

Rhythm

SpO2

Time

HR

RR

BP

Cardiopulmonary Resuscitation (CPR) Flow Sheet

Form #N5516

Guidelines

Procedure: Date and time is per facility Military vs. Standard. Time of Arrival in ED: Check N/A if arrest occurs within the facility. Location refers to pre or in hospital. Initial VS: Enter the initial vital signs of patient on arrival to the ED or as assessed by the code team. History of Event: Include narrative notes regarding events leading up to arrest. It should also include relevant pre-hospital procedures/treatments. Procedures Performed: Artificial Ventilation: Enter adjunctive airway and rate of respiration. Intubated: Enter the time, size of tube inserted, name of person performing the procedure, and number of attempts. Indicate placement, confirmation of placement and tube secured at. NG/OG Tube (circle one): Enter time, size, and name of person performing procedure. Intraosseous: Enter time, size, site of needle insertion, and person performing the procedure. Venipuncture: Enter time, size, site of catheter, person performing procedure, and number of attempts. Central Venous Catheter: Enter time, size, site of catheter, and person performing procedure. Foley Catheter: Enter time, size of catheter placed, and the person performing the procedure. Interventions: Medications: Use blank spaces to document additional medications and dosages given. EPI 1:1,000: Enter number of mg administered. EPI 1:10,000: Enter number of mg administered. Rhythm: Enter response to defibrillations and interventions. IV Meds/Fluids: Dopamine: Enter the concentration of solution on the line provided & the rate of administration in the space provided. Lidocaine: Enter the concentration of solution on the line provided & the rate of administration in the space provided. Fluid IV Bolus: Enter the number of ccs administered or infused. Blank spaces: Use to document additional IV fluid/medication drips given. ABG Drawn: Indicate time arterial blood gas drawn. Nurses Notes: Include documentation of specific notes. See triggers. Outcome: Complete as appropriate. Individuals present at code: List the names and titles of all personnel present. Signatures: Obtain the signatures of the documenting nurse and the physician managing code. Note: The physicians signature allows this form to serve as a verification of the code process and all medication/intervention orders. Patient Identification Area: Stamp with the patients addressograph plate. Because this form is intended for use at several facilities, the addressograph should include facility identification information in addition to patient information.

N5516 Rev. (12/31/2003)