MCD00130 Adult and Pediatric Co

Date:Time Event Recognized:Location of Event:Witnessed? ☐Yes ☐No

Age :______Weight :______Gender :______Race:______Hospital-wideresuscitation responseactivated? ☐Yes ☐No

RecorderSignature:

Recorder Printed Name:

ProviderPrinted Name:______

Provider Signature: _______

Illness Category

☐MedicalCardiac☐MedicalNoncardiac☐Newborn☐Obstetric Pre Event MEWS Score: ______

☐SurgicalCardiac☐SurgicalNoncardiac☐Trauma☐Other______PreEvent PEWS Score: ______

RecorderSignature:

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Condition when needforchestcompressions/defibrillation was identified?☐Pulseless☐Pulse(poorperfusion)

Interventions Already in Place: ☐Assisted or mechanical ventilation (includes CPAP/BiPAP) ☐Intra-arterial catheter ☐ETCO2 monitoring

☐Vascular Access ☐Vasoactive drug ☐ Supplemental O2 Monitoring at Onset: ☐ECG ☐Pulse Oximeter

RecorderSignature:

Recorder Printed Name:

ProviderPrinted Name:______

Provider Signature: _______

Timeof First Assisted Ventilation: FirstRhythmRequiring Compressions: ______

Time / Spontaneous
Assisted() / Spontaneous
Compression() / BP / Rhythm / ETCO2 / Joules / Amiodarone
Dose/IVorIO / Atropine
Dose/IVorIO / Epinephrine
Dose/IVorIO / Lidocaine
Dose/IVorIO / Vasopressin
Dose/IVorIO / Dopamine / Epinephrine / Norepinephrine / Comments:
i.e.:Peripheral/CentralLinePlacement,
IO,ChestTube,VitalSigns,
ResponsetoInterventions

Ventilation: ☐BVM ☐ ETT ☐ LMA☐ Tracheostomy tube First Documented PULSELESS Rhythm: ______

☐ Mask or Nasal CPAP/BiPAP ☐Other ______TimeChestCompressionsStarted:______

Invasive Airway: ☐In place at time event ☐Inserted ☐ReinsertedCompression Method Used: ☐Standard manual ☐IAC-CPR

If inserted/reinserted: Bywhom: ______☐Active Compression-Decompression Device

Time: ______☐Automatic Compressor ☐Open Chest ☐Other______

Confirmation: ☐ Waveform ETCO2 ☐ Numeric ETCO2 AED or Defibrillator in AED mode applied? ☐Yes ☐No

☐ Color ETCO2 ☐Direct laryngoscopy If yes, time AED applied: ______

Time Event Ended: ______Status: ☐Survived - ROC ☐Expired - Efforts terminated, no ROC

Was CPR Performance Monitored or Guided by? ☐WaveformETCO2 ☐Arterial Waveform/Diastolic Pressure☐CPR Mechanics Device

☐Metronome ☐Other ______

Recorder Signature: ______

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Provider Printed Name: ______

RecorderSignature:

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RecorderSignature:

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RecorderSignature:

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Progress Notes(Continuation)

RecorderSignature:

Recorder Printed Name:

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Provider Signature: _______