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    Form Dokumentasi Resusitasi

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    sy_ajoekoe
    This document is a code record for a patient that required resuscitation. It records details of the patient's condition at onset, interventions performed, medications administered, rhythms observed, and outcome. Key details include the patient initially had a pulse but poor perfusion requiring compressions, their first rhythm was ventricular fibrillation, compressions and defibrillation were performed, epinephrine and vasopressin were administered, and resuscitation efforts were ultimately terminated after 20 minutes without return of circulation.

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    © All Rights Reserved
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    Form Dokumentasi Resusitasi

    Uploaded by

    sy_ajoekoe
    352 views1 page
    This document is a code record for a patient that required resuscitation. It records details of the patient's condition at onset, interventions performed, medications administered, rhythms observed, and outcome. Key details include the patient initially had a pulse but poor perfusion requiring compressions, their first rhythm was ventricular fibrillation, compressions and defibrillation were performed, epinephrine and vasopressin were administered, and resuscitation efforts were ultimately terminated after 20 minutes without return of circulation.

    Original Description:

    formulir dokumentasi tindakan resusitasi/code blue

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    This document is a code record for a patient that required resuscitation. It records details of the patient's condition at onset, interventions performed, medications administered, rhythms observed, and outcome. Key details include the patient initially had a pulse but poor perfusion requiring compressions, their first rhythm was ventricular fibrillation, compressions and defibrillation were performed, epinephrine and vasopressin were administered, and resuscitation efforts were ultimately terminated after 20 minutes without return of circulation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    352 views1 page

    Form Dokumentasi Resusitasi

    Uploaded by

    sy_ajoekoe
    This document is a code record for a patient that required resuscitation. It records details of the patient's condition at onset, interventions performed, medications administered, rhythms observed, and outcome. Key details include the patient initially had a pulse but poor perfusion requiring compressions, their first rhythm was ventricular fibrillation, compressions and defibrillation were performed, epinephrine and vasopressin were administered, and resuscitation efforts were ultimately terminated after 20 minutes without return of circulation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Facility Name / Logo Patient Label

    Date___________ Time Event Recognized ___________ Location______________ Witnessed: Yes No


    Age _________Weight___________ Height _________ Hospital-wide resuscitation response activated? Yes No
    Illness Category: Medical Cardiac Medical Noncardiac Newborn Obstetric
    Surgical Cardiac Surgical Noncardiac Trauma Other ______________
    Condition when need for chest compression/defibrillation was identified? Pulseless Pulse (poor perfusion)
    Did the patient with a pulse requiring compressions become pulseless? Yes No
    Was patient conscious at onset? Yes No Monitoring at onset: ECG Pulse Oximeter Apnea
    Airway/ Ventilation First Rhythm Requiring Compressions: ______________
    Breathing at Onset: Spontaneous Apneic Agonal Assisted First Documented PULSELESS Rhythm: _____________
    Time of First Assisted Ventilation: ____________________ Compressions: None Manual Device:________
    Ventilation: Bag-Valve-Mask Endotracheal Tube Time chest compressions started: __________________
    Tracheostomy Other:_______________ Impedance Threshold Device used? Yes No
    Intubation: Time:________ Size :_______ AED applied: Yes No  Time applied:__________
    By Whom: ____________________________________________ Defibrillator type(s): ______________________________
    Confirmation Auscultation Exhaled CO2 Other Pacemaker On: Yes No
    Bolus ~ Dose / Route Infusions ~ Dose / ml per hour
    Breathing Pulse
    Dose / IV or IO

    Dose / IV or IO

    Dose / IV or IO

    Dose / IV or IO

    Dose / IV or IO

    Norepinephrine
    )

    Amiodarone

    Epinephrine

    Epinephrine
    Comments:
    Vasopressin
    Compression (
    Spontaneous

    Spontaneous

    Dobutamine
    )

    )
    Assisted (

    Dopamine
    Manual (

    Lidocaine
    i.e.: Peripheral/Central Line
    Atropine
    Rhythm
    BP

    Time Placement, IO, Chest tube,


    Joules

    Vital Signs, Response to


    AED

    Interventions

    Time Resuscitation Event Ended: ___________________ Status: Alive Dead


    Reason Resuscitation Ended: Return of Circulation (ROC) >20 min Efforts Terminated (No Sustained ROC)
    Medical Futility Advance Directives Restrictions by Family
    Recorder Signature ______________________ID#_________ Provider Printed Name __________________ID#_________
    ICU/Team Nurse Signature _______________________ ID#_________ Provider Signature __________________________
    Page ____of _____ Original:_____________ Yellow:_____________ Provided by American Heart Associations GWTG-R

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