CODE 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]