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: |

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|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: |

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|Team members, PRINT names and grades |

|Team Leader: |

|Anaesthetics: |

|ODP: |

|Others: |

|Form completed by: |

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Date: __________ Time (of 2222 call): ________

Site: RSCH/RACH/PRH

Ward/Area: _________________________

Affix patient label

Name:

Date of birth:

Hospital Number:

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