Escolar Documentos
Profissional Documentos
Cultura Documentos
Rhythm Response
Dopamine
Lidocaine
EPI 1:10,000
IV Fluid Bolus
Rhythm
Nurse’s Notes
1:1,000EPI
Lidocaine
SpO2
Time
Atropine
HR
RR
BP
Pupils, Procedures, etc.)
Was the patient successfully resuscitated? Yes No Patient expired at Pronounced by PATIENT IDENTIFICATION
Time code terminated Disposition of Patient: Time Location
Family notified Attending called
Names of all individuals present at code:
Physician Signature/Arrest Order Verification
Cardiopulmonary
Resuscitation Flow Sheet R.N. Signature
N5516 Rev. (12/31/2003)
Cardiopulmonary Resuscitation (CPR) Flow Sheet Guidelines
Form #N5516
Procedure:
Date and time is per facility – Military vs. Standard.
Time of Arrival in ED: Check N/A if arrest occurs within the facility. Location refers to pre or in hospital.
Initial VS: Enter the initial vital signs of patient on arrival to the ED or as assessed by the code team.
History of Event: Include narrative notes regarding events leading up to arrest. It should also include relevant pre-hospital
procedures/treatments.
Procedures Performed:
Artificial Ventilation: Enter adjunctive airway and rate of respiration.
Intubated: Enter the time, size of tube inserted, name of person performing the procedure, and number of attempts.
Indicate placement, confirmation of placement and tube secured at.
NG/OG Tube (circle one): Enter time, size, and name of person performing procedure.
Intraosseous: Enter time, size, site of needle insertion, and person performing the procedure.
Venipuncture: Enter time, size, site of catheter, person performing procedure, and number of attempts.
Central Venous Catheter: Enter time, size, site of catheter, and person performing procedure.
Foley Catheter: Enter time, size of catheter placed, and the person performing the procedure.
Interventions:
Medications: Use blank spaces to document additional medications and dosages given.
EPI 1:1,000: Enter number of mg administered.
EPI 1:10,000: Enter number of mg administered.
Rhythm: Enter response to defibrillations and interventions.
IV Meds/Fluids:
Dopamine: Enter the concentration of solution on the line provided & the rate of administration in the space provided.
Lidocaine: Enter the concentration of solution on the line provided & the rate of administration in the space provided.
Fluid IV Bolus: Enter the number of cc’s administered or infused.
Blank spaces: Use to document additional IV fluid/medication drips given.
ABG Drawn: Indicate time arterial blood gas drawn.
Nurse’s Notes: Include documentation of specific notes. See triggers.
Outcome: Complete as appropriate.
Individuals present at code: List the names and titles of all personnel present.
Signatures: Obtain the signatures of the documenting nurse and the physician managing code.
Note: The physician’s signature allows this form to serve as a verification of the code process and all
medication/intervention orders.
Patient Identification Area: Stamp with the patient’s addressograph plate. Because this form is intended for use at several
facilities, the addressograph should include facility identification information in addition to patient information.
N5516 Rev. (12/31/2003)