Form Code Blue

CODE BLUE FORM

PATIENT IDENTIFICATION START DATE:

TIME:

CONDITION:

OF

CODE

(Military Time) FOUND BY:

FOR INTUBATION ONLY

LOCATION:

 APNEIC

PULSELESS

R ES US CI TA TI ON

OTHER: __________________________  

E FF OR TS

MD IN CHARGE:

CPR Initiated

Military TIME

Intubation

Military TIME

Central Line Placement

Military TIME

Other 

( Describe ) > >

Military TIME

DRUGS D RU GS / F LU ID / R AT E

TIME / DOSE TIME / DOSE TIME / DOSE TIME / DOSE TIME / DOSE TIME / DOSE

 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

I .V . / F LU ID / R AT E

TIME TIME / RATE RATE TIME TIME / RAT RATE E TIME TIME / RATE RATE TIME TIME / RATE RATE TIM TIME E / RATE RATE TIM TIME E / RATE RATE

 I.V. Fluid INTERVENTIONS

TIME

TIME

TIME

TIME

TIME

TIME

 Rhythm / HR  B P  Defib Time / Joules  Pacer / Time / MA  Labs / ABGs Sent R ES US CI TA TI ON RECOVERY

TIME STOPPED: ____________ 

BP: _________

O UT CO ME

HR: _________

RR: _________

RHYTHM: _________  

RECEIVING UNIT: DEATH

TIME OF DEATH: DEATH: _______ ____________ __________ _____

MD SIGNATURE:

PMD NOTIFIE NOTIFIED D BY: __________ _______________ __________ __________ __________ __________ __________  _____  RN SIGNATURE / TITLE:

WHITE COPY = Chart

YELLOW COPY = ICU Medical Director

PINK COPY = Pharmacy

PART OF THE MEDICAL RECORD 8850447 Rev. 05/05

Code Blue Form_NURSING

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