r*NE504*r

PROVIDENCE HOSPITAL
6801 Airport Boulevard, Mobile AL 36608,
251/633−1000

NE5044

Date: _______________

Mode of Arrival:

PRE−Hospital EFFORTS:
AIRWAY ❑ BVM ❑ ETT:
Time of Arrival/CODE _______________

❑ Ambulance/Helicopter Company/ UNIT __________

Providence Hospital
CODE BLUE RECORD
USE MILITARY TIME

PED: Tape color/weight _______________

❑ Automobile ❑ IN DEPARTMENT / HOSPITAL: UNIT _______________

TO BE USED ONLY IN THE EMERGENCY DEPARTMENT FOR PRE−Hospital CODES

Size:_____/ ________cm @TEETH Placement confirmation ❑ ETCO2/EAD ❑ Breath Sounds

CIRCULATION: ❑ CPR: Time started _____________ ❑ Defibrillation x _____________ First Rhythm __________________
❑ IV/IO # 1 ______g in ________ # 2 ______g in ________ Fluids: ❑ Yes ❑ No if yes: Type _________________ rate: ____________________
DRUG THERAPY: ❑ epinephrine last dose __________ ❑ vasopressin last dose __________ ❑ atropine last dose ___________
❑ lidocaine ❑ amiodarone (CORDARONE) ❑ Other _______________ ❑ Other _______________ ❑ Other _______________
IN DEPARTMENT/HOSPITAL: TO BE FILLED OUT ON IN−HOUSE CODES
Who discovered code? _________________________ Monitored ❑ Yes _________________________ ❑ No
AIRWAY: At Onset: ❑ Spontaneous ❑ Apneic ❑ Agonal ❑ Assisted
Placement confirmation ❑ ETCO2 ❑ Breath Sounds ❑ CHEST X−RAY
❑ ETT: Size: _______/__________ cm @ TEETH by __________ time: ________

CIRCULATION: RHYTHM ____________________ ❑ PULSE Yes or No ❑ CPR started _______________ (time)

IV: IN PLACE ❑ IV/IO # 1 ______g in ________ # 2 ______g in _________ STARTED BY ____________________
Fluids: ❑ Yes ❑ No if yes: Type____________________rate@____________________

Time Rhythm Drug Dose Interventions/Procedures/Consultations: Vital Signs

Drips Started

DATE PRINTED: 0−12−−1 NSG00048a

 NE5044

Time
r*NE504*r
Rhythm Drug Dose
Drips Started
Providence Hospital
CODE BLUE RECORD
USE MILITARY TIME

Interventions/Procedures/Consultations: Vital Signs

Resuscitation Event Ended @ __________ Status: ❑ Alive ❑ Expired Patient pronounced at:__________ ❑ Transferred to ___________

Reason Resuscitation Ended: ❑ Return of Circulation ❑ Medical Futility ❑ Restrictions by Family ❑ Advance Directives

Physician:________________, Recorder________________, Nurse 1/ Captain________________, Nurse 2/ Co−Captain________________

Respiratory 1___________________, Respiratory 2___________________, Pharmacist___________________, Other___________________

Emergency Room Only

If Expired: ❑ Family Notified by ____________________ at ____________ Primary Physician: Dr. ________________ notified at _____________

Body to: ❑ Morgue ❑ ______________________________

Coroner Case: ❑ Yes ❑ No If yes, ADFS notified at _______________ spoke with _________________________

Developed: 2/82 Revised: April 2008

DATE PRINTED: 0−12−−1
NSG000048b