Resuscitation Record Sheet and Audit Form
Cardiac Arrest Record
|Time |Rhythm |Shock |Drugs given and other interventions/occurrences |
| | |energy | |
|hh:mm |Write the rhythm |e.g. 360j |e.g. Adrenaline 1mg, Amiodarone 300mg, Amiodarone 150mg, Alteplase 50mg, etc |
| | | |e.g. ROSC, IV Access, IO Access, Intubation, LUCAS, etc |
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|Patient’s Consultant: | |Patient’s Nurse: |
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|Admission details | |Resuscitation details |
|Date of admission: | |Was the arrest witnessed: Yes/No |
| | |Was the arrest monitored: Yes/No |
|Reason for admission: | |Likely/known cause of cardiac arrest: |
| | | |
|Diagnosis: | | |
| | |Interventions |
|Medical Hx: | |LMA/i-Gel |
| | |Intubation |
| | |Capnography |
| | |LUCAS |
| | |IO access |
|Last NEWS score: | |Therapeutic hypothermia |
| | |Other (specify): |
|Time of last NEWS: | | |
| | | |
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|Reason CPR stopped | |Planned location after event |
|ROSC | |Mortuary |
|Team decision to stop | |Remained on ward |
|DNACPR form found | |ITU/HDU |
|Other (specify): | |Cath Labs |
| | |CCU |
|Resuscitation decision post ROSC | |Other (specify): |
|For CPR | | |
|DNACPR | | |
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|In your opinion was this resuscitation attempt appropriate: Yes/No |
|If your opinion is no, please state why: |
| | | |
|Team members, PRINT names and grades |
|Team Leader: |
|Anaesthetics: |
|ODP: |
|Others: |
|Form completed by: |
-----------------------
Date: __________ Time (of 2222 call): ________
Site: RSCH/RACH/PRH
Ward/Area: _________________________
Affix patient label
Name:
Date of birth:
Hospital Number:
................
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