Code blue documentation is the record of a cardiac arrest in hospital: the running timeline written during the resuscitation, and the code note that sums it up afterward. Copy the free template, see a witnessed VF arrest with return of circulation and an unwitnessed PEA arrest from pulmonary embolism, and check what each part needs.
Blank code blue documentation template
FreeCODE BLUE DOCUMENTATION Patient: [Name] Date of birth or ID: [Identifier] Location: [Unit and room] Date: [Date] Admitted for: [Reason for admission and hospital day] Code status before the event: [Full code, or limits on treatment, and where they are documented] PART 1: RESUSCITATION RECORD EVENT Found or collapsed: [Time] Found by: [Name and role] Witnessed: [Yes, by whom; or no, and the time last seen well] Monitored: [Telemetry, pulse oximetry, or none] CPR started: [Time, and by whom] Code blue called: [Time] Clock used: [Defibrillator clock or wall clock, and any difference between them] TEAM Team leader: [Name and role] Airway: [Name and role] Compressions: [Names, and how often they changed] Defibrillator and monitor: [Name] Medications: [Name] Recorder: [Name] Others: [Pharmacist, respiratory therapist, anesthesia, ICU, or chaplain, with arrival times] TIMELINE [Time] Rhythm check: [Rhythm; pulse present or absent] [Time] Shock: [Shock number and energy in joules] [Time] Medication: [Drug, dose, route] [Time] Airway or access: [Device, size, site, who placed it, how it was confirmed] [Time] Test or finding: [Ultrasound, blood gas, potassium, end-tidal CO2, and the result] [Time] Decision: [What the team decided, why, and who decided] [Repeat for each event, in order, from one clock] PART 2: CODE SUMMARY NOTE SUMMARY Initial rhythm: [VF, pulseless VT, PEA, or asystole, and any later change] Shocks: [Total number and energy] Medications: [Each drug, the total doses, and the times of the first and last dose] Airway: [Device, time placed, and confirmation by waveform capnography] Access: [IV or IO, site, and time] CPR quality: [End-tidal CO2 values, compressor changes, and pauses] REVERSIBLE CAUSES H's: [Hypoxia, hypovolemia, acidosis, high or low potassium, hypothermia: what was checked and found] T's: [Tension pneumothorax, tamponade, toxins, pulmonary embolism, coronary thrombosis: what was checked and found] Cause treated: [The likely cause, and the treatment given for it] OUTCOME Result: [Return of spontaneous circulation at a time; or resuscitation stopped at a time] Total time: [Minutes from the start of CPR to ROSC or to stopping] After ROSC: [Rhythm, blood pressure, oxygen saturation, end-tidal CO2, and whether the patient follows commands] Post-arrest plan: [12-lead ECG, cardiology or cath lab, temperature control, targets, and destination] If resuscitation stopped: [Reason, who agreed, time of death, who pronounced, and where the pronouncement note is] COMMUNICATION Family or decision-maker: [Name, relationship, time told, and by whom; present during the resuscitation or not] Attending and primary team: [Name, time informed, and how] Others informed: [ICU, cardiology, pharmacy, or others] DEBRIEF Held: [Time, place, who led it, and who attended] Went well: [What helped the resuscitation] To improve: [Delays, equipment, or communication problems] Follow-up: [Each action, its owner, and any safety report or code review] Recorded by: [Recorder name, credentials, time signed] Signed by team leader: [Name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Cardiac ward, daytime, team leader’s code note with the recorder’s timeline
Cardiac ward, bed 14, November 3. 62-year-old man, hospital day 2 with a non-ST-elevation myocardial infarction, on aspirin and a heparin infusion; coronary angiography booked for this afternoon. Full code, confirmed on admission. Collapsed at 10:42 while his nurse, Grace Lim, RN, was in the room: witnessed. On telemetry, which showed ventricular fibrillation at 10:42. CPR started by his nurse at 10:42; code blue called at 10:42. Times from the defibrillator clock, which matched the wall clock.
Team leader: Dr. Priya Nair, hospitalist. Airway: Sam Duarte, respiratory therapist; Dr. Kim, anesthesia, from 10:50. Compressions: Grace Lim, RN, and two ward nurses, changing every 2 minutes. Defibrillator: Tom Reyes, RN, charge nurse. Medications: Alicia Ford, RN, critical care outreach. Recorder: Jen Walsh, RN, from 10:45. Pharmacist from 10:46. Cardiology fellow from 10:58.
10:42 Collapse; VF on telemetry. CPR started, code blue called. 10:43 Pads on; VF. Shock 1, 200 J biphasic; CPR resumed at once. Bag-mask ventilation with 100% oxygen, 30 compressions to 2 breaths. 10:44 Code team arrived. Existing 20-gauge IV, right forearm, flushed and working. 10:45 Rhythm check: VF. Shock 2, 200 J; CPR. 10:46 Epinephrine 1 mg IV. 10:47 Rhythm check: VF. Shock 3, 200 J; CPR. 10:48 Amiodarone 300 mg IV. End-tidal CO2 on the bag-mask rose suddenly from 24 to 45 mmHg. 10:49 Rhythm check: sinus tachycardia at 108; carotid and femoral pulses present. ROSC. 10:50 Second IV, 18-gauge, left antecubital. 10:51 BP 94/60, SpO2 97%. 10:52 Blood gas sent. 10:53 12-lead ECG: ST elevation in II, III, and aVF, with ST depression in V1 to V3. 10:54 Cath lab activated. 10:55 Bedside ultrasound. 10:56 Intubated by Dr. Kim: 7.5 tube at 23 cm at the teeth, confirmed by waveform capnography. 11:10 To the cath lab. Entries from 10:42 to 10:44 taken from the defibrillator’s event record.
Initial rhythm VF, witnessed and monitored. CPR at once; first shock 1 minute after collapse. 3 shocks, each 200 J biphasic. Epinephrine 1 mg IV, 1 dose, at 10:46, after the second shock. Amiodarone 300 mg IV at 10:48, after the third shock; the second dose wasn’t needed. Bag-mask during CPR; intubated after ROSC at 10:56. Access: the existing right forearm IV, then a second line at 10:50. CPR quality: compressors changed every 2 minutes; each rhythm check paused compressions for under 10 seconds on the defibrillator record; end-tidal CO2 18 to 24 mmHg during CPR.
Coronary thrombosis: the likely cause, with a myocardial infarction on admission and new inferior and posterior ST changes after ROSC. Hypoxia: SpO2 96% on 2 L before the arrest; ventilated with 100% oxygen. Potassium 4.1 mmol/L on the morning labs and 3.9 on the blood gas at 10:52; pH 7.24, lactate 4.8 mmol/L. Hypovolemia, hypothermia, and toxins: nothing to suggest them. Tension pneumothorax: equal breath sounds on both sides after intubation. Tamponade: no pericardial effusion on ultrasound at 10:55; left ventricular function moderately reduced, with the inferior wall moving poorly. Cause treated: emergency angiography.
ROSC at 10:49, after 7 minutes of CPR. Sinus tachycardia at 108, BP 94/60, SpO2 97%. Not following commands after ROSC: GCS 5, with eyes 1, verbal 1, and motor 3. Post-arrest plan, agreed with cardiology and the ICU: emergency coronary angiography for inferior ST elevation; temperature control because he doesn’t follow commands, target 36°C for at least 36 hours, then preventing fever, starting in the cath lab; mean arterial pressure at least 65 mmHg; SpO2 90 to 98%; PaCO2 35 to 45 mmHg; EEG if seizures are suspected. Cardiac ICU bed confirmed. To the cath lab at 11:10 with the cardiology fellow, the outreach nurse, and the respiratory therapist.
His wife, Maria, his decision-maker, called by Dr. Nair at 11:02. Told that his heart stopped, that it restarted after 7 minutes of CPR and 3 shocks, that he is having an emergency angiogram, and that it is too early to know how his brain has recovered. She is on her way; the cardiac ICU charge nurse will meet her. Attending cardiologist, Dr. Byrne, informed by phone at 10:54 and in the cath lab for the procedure. ICU informed at 10:55.
Hot debrief on the ward at 11:20, 10 minutes, led by Dr. Nair; 7 of the team present. Went well: a shock within 1 minute of collapse, clear roles, and closed-loop drug orders. To improve: the wall suction wasn’t set up, so suction was delayed by about a minute; the recorder arrived at 10:45, so the first minutes came from the defibrillator. Follow-up: suction added to the unit’s daily bedside check, charge nurse, by Friday; defibrillator record downloaded for the code review; staff support offered.
Medical ward, overnight, resuscitation stopped after thrombolysis
Medical ward, room 8, November 7. 67-year-old woman, hospital day 2 with bilateral pulmonary emboli: CT showed a saddle embolus with a dilated right ventricle, troponin raised, blood pressure normal on admission; on a heparin infusion. Full code, confirmed with her and her husband yesterday. Found unresponsive and not breathing at 04:18 by her nurse, Hana Mori, RN, after a low oxygen alarm. Not witnessed; last seen well at 04:00, talking, with heart rate 112, BP 104/68, and SpO2 93% on 4 L. On continuous pulse oximetry, not telemetry. No pulse; CPR started by her nurse at 04:18; code blue called at 04:18. All times from the defibrillator clock, which ran 1 minute ahead of the wall clock.
Team leader: Dr. Luis Ortega, night hospitalist; Dr. Sam Ray, ICU fellow, led from 05:20 to 05:22. Airway: Dr. Amy Chen, anesthesia, from 04:22, with Nate Bell, respiratory therapist. Compressions: four nurses, changing every 2 minutes. Defibrillator: Paul Grant, RN. Medications: Rita Sousa, RN. Recorder: Lena Brooks, RN, charge nurse. Pharmacist, Dan Wu, from 04:23. ICU fellow from 04:30. Chaplain from 05:15.
04:18 Found unresponsive, not breathing, no carotid pulse. CPR started, code blue called. 04:20 Team arrived; pads on. Rhythm check: PEA, narrow complexes at 40 a minute, no pulse. CPR; bag-mask with 100% oxygen, 30 to 2. Heparin infusion stopped. 04:21 Epinephrine 1 mg IV, existing left forearm line. 04:22 Rhythm check: PEA at 36, no pulse. Ultrasound in the pause: right ventricle much larger than the left, no coordinated contraction, no pericardial effusion. Pharmacy asked for alteplase. 04:23 Pharmacist arrived with alteplase from the ICU. 04:24 Rhythm check: PEA, no pulse. Intubated by Dr. Chen: 7.0 tube at 21 cm, confirmed by waveform capnography; end-tidal CO2 16 mmHg; lung sliding on both sides. Continuous compressions with 10 breaths a minute from here. Second IV, 18-gauge, right antecubital. 04:25 Epinephrine 1 mg IV. Decision, Dr. Ortega: arrest from known massive pulmonary embolism; give alteplase. No recent surgery, stroke, or bleeding. 04:26 Rhythm check: PEA, no pulse. Alteplase 50 mg IV bolus. Plan: continue CPR for at least 60 minutes after alteplase unless circulation returns. 04:29 to 05:25 Epinephrine 1 mg IV every 4 minutes. 04:34 Blood gas: pH 6.98, lactate 11.2 mmol/L, potassium 4.6 mmol/L. 04:50 Rhythm check: asystole, and at every check after. 05:04 Ultrasound: no cardiac motion; end-tidal CO2 9 mmHg. 05:15 Husband arrived and chose to stay, with the chaplain and a nurse beside him. 05:24 Ultrasound: no cardiac motion; end-tidal CO2 6 mmHg. 05:26 Rhythm check: asystole. Resuscitation stopped.
Initial rhythm PEA, unwitnessed; asystole from 04:50. No shocks: no shockable rhythm at any check. Epinephrine 1 mg IV, 17 doses, from 04:21 to 05:25. Alteplase 50 mg IV at 04:26. Airway: bag-mask, then an endotracheal tube at 04:24, confirmed by waveform capnography. Access: the existing left forearm IV, and a right antecubital line at 04:24. CPR quality: compressors changed every 2 minutes; end-tidal CO2 14 to 18 mmHg for the first 30 minutes, then falling to 6.
Pulmonary embolism: the cause, with a known saddle embolus and a dilated right ventricle on ultrasound; treated with alteplase. Hypoxia: intubated on 100% oxygen, tube position confirmed. Hypovolemia: no bleeding seen before or after alteplase. Acidosis: pH 6.98 at 04:34, from the arrest; bicarbonate not given. Potassium 4.6 mmol/L. Hypothermia: normal temperature at 04:00. Tension pneumothorax: lung sliding on both sides. Tamponade: no pericardial effusion. Toxins: no new drugs; no opioids in the last 12 hours. Coronary thrombosis: not suspected.
No return of spontaneous circulation. Resuscitation stopped at 05:26 after 68 minutes of CPR and 60 minutes after alteplase: asystole at every check from 04:50, no cardiac motion on ultrasound at 05:04 and 05:24, and end-tidal CO2 falling from 16 to 6 mmHg. Agreed by Dr. Ortega, Dr. Ray, and the team, with no one objecting; her husband was told before the final check. Pronounced dead at 05:31 by Dr. Ortega after 5 minutes of observation. Exam, notifications, reporting, and donation are in the death pronouncement note.
Her husband, her decision-maker, called by the nursing supervisor at 04:30 and told she was having CPR. He arrived at 05:15 and chose to be present. Dr. Ortega spoke with him at 05:20, while Dr. Ray led: alteplase had been given, her heart had not restarted, and the team would stop if the next checks were unchanged. He said she “wouldn’t want them to keep going for nothing.” Told of her death by Dr. Ortega at 05:32. Attending, Dr. Wells, informed by phone at 05:45.
Hot debrief at 05:50 in the ward meeting room, 15 minutes, led by Dr. Ray; 8 of the team present. Went well: CPR within seconds of finding her, intubation at 6 minutes, and alteplase 8 minutes after the code was called. To improve: alteplase isn’t stocked on the ward, so it took 4 minutes from asking to giving; compressors tired after 40 minutes with no mechanical compression device on the ward. Follow-up: pharmacy to review where alteplase is kept for ward codes; case sent to the resuscitation committee; peer support offered, and the night manager checked in with her nurse.
The first minutes: when the patient collapsed or was found, by whom, whether anyone saw it, and how fast CPR started. Witnessed and monitored arrests have better outcomes, so record it either way.
Avoid: “Found unresponsive” with no last-seen time. The gap between last seen well and the start of CPR matters to the team, the family, and the code review.
Who led the code and who did each job. The recorder writes this first, adding people as they arrive.
Avoid: A list of names with no roles. The code review asks who decided, who gave each drug, and who placed the airway.
The resuscitation record itself: a running log, written live by the recorder, of each rhythm check, shock, drug, procedure, and decision against one clock. Rhythm checks come about every 2 minutes.
Avoid: Rebuilding the timeline from memory. If the recorder started late, fill the early minutes from the defibrillator’s event record, and say which entries came from it.
The top of the code note: the totals from the timeline, so a reader sees the resuscitation at a glance. The 2025 American Heart Association guidelines, and the Heart and Stroke Foundation’s edition of them, give epinephrine 1 mg every 3 to 5 minutes: as soon as possible for PEA or asystole, and after the first shocks fail for VF or pulseless VT. For VF or pulseless VT that persists after shocks, the algorithm adds amiodarone 300 mg, then 150 mg, or lidocaine.
Avoid: “ACLS given per protocol.” Write what was given and when, so a reader can check it against the algorithm.
The H’s and T’s: what the team looked for, how, and what it found. The likely cause of the arrest, and its treatment, goes here.
Avoid: “H’s and T’s considered.” Write the finding beside each one, such as “no pericardial effusion on ultrasound.”
How the resuscitation ended: return of spontaneous circulation and the plan after it, or the decision to stop and the time of death.
Avoid: “ROSC achieved” with no time or exam. The ICU and cath lab teams plan from the minutes of CPR and whether the patient follows commands.
Who was told, when, and by whom. Many hospitals offer the family the chance to be present during the resuscitation, with a staff member beside them.
Avoid: Leaving the family call for later. Record who called, when, and what they were told, even if it was only that CPR was under way.
A short team talk after the code, straight away or later, and what it changes. Some organizations keep it in the chart; others keep it in a separate quality review record.
Avoid: Naming one person’s errors in the patient’s chart. Record what happened to the system and the equipment, and follow your organization’s policy on where debrief notes go.
The defibrillator, the monitor, the wall clock, and phones rarely agree. Pick one, write which, and note any difference, so the drug times line up with the rhythm strips.
Name a recorder at the start whose only job is the record. Times written from memory after a code are often minutes off, and drug intervals can’t be checked.
“Epinephrine x4” doesn’t show whether doses came every 3 to 5 minutes. Write each dose with its time, or the interval and the first and last times.
A ticked list of H’s and T’s says nothing. Write what was checked and what it showed, and what was treated.
Whether the code ended in ROSC or the team stopped, write the time, and why. When the team stops, record who agreed and that the family was told.
Vero Scribe writes the code note in your template from your dictation after the code, with the recorder’s timeline in front of you. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
During the code, the recorder keeps a running timeline from one clock: each rhythm check, shock, drug, and procedure, with its time. Afterward, the team leader writes the code note: how the arrest was found, the initial rhythm, the totals for shocks and drugs, the airway and access, the reversible causes checked, the outcome, who was told, and the debrief.
The time of collapse or discovery, whether it was witnessed, the initial rhythm, and the time CPR started. Then each shock with its energy, each drug with its dose, route, and time, the rhythm at each check, the airway and access, and the time of ROSC or of stopping. Add the team leader and recorder by name. These are also the times code reviews and cardiac arrest registries collect.
One team member, often a nurse, is named the recorder and does nothing else. They write each event as it happens and call out drug timing, such as when the next epinephrine dose is due. The team leader checks the record and writes or signs the code note. Your organization’s policy sets who signs which part.
The code note records the resuscitation: what was done, when, and how it ended. If the patient dies, a death pronouncement note follows, recording the exam that confirms death, the time of death, who was told, and reporting and donation. The code note names the time of death and who pronounced, and points to the pronouncement note.
Yes. Copy it, or download it as a Word or text file. No account needed.
The daily inpatient note: overnight events, trends, a plan by problem, and the daily checklist.
The full adult admission workup, with medication reconciliation, goals of care, and level of care.
Answer another team’s question: a focused history, a direct answer, and numbered recommendations.
The note that moves with the patient between units or hospitals: reason, course, problems, devices, and who follows what.
The record of a hospital stay: diagnoses, course by problem, procedures, medicine changes, pending results, follow-up, and code status.
Admission, daily, and code notes, drafted for your review.
ICU admissions, procedures, and family meetings, documented for your review.
Resuscitations and emergency visits, drafted for your review.
The codes used most often in hospital medicine.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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