Page     of    

Date Time of Arrival in ED Time & Location of Arrest Hx of Event

      N/A                  
Type of Arrest: Cardiac Respiratory Witnessed Unwitnessed
CPR Started EMS ALS Started EMS
      Bystander       Hospital Staff
Initial BP T P R Wt.
VS                               
Procedures Performed
Artificial Ventilation: Bag/Mask       Bag/Endo Tube       Intraosseous: Time       Size & Site       By       No. Attempts
Intubated: Time       Size       By       No. Attempts     Venipuncture: Time       Size & Site       By      
   Attempts
No.
Oral Nasal Cric Trach Placement Confirmed By       Venipuncture: Time       Size & Site       By      
   
No. Attempts
Tube Secured At (cm)       Central Venous Catheter: Time       Size & Site      
    By      
NG/OG Tube: Time       Size       By       Foley Cath: Time       Size       By      
Medications (* if given by ET Tube) IV Meds/Fluids

Rhythm Response

ABG Drawn ()

Defib. Joules

     Dopamine

     Lidocaine
EPI 1:10,000

IV Fluid Bolus
Rhythm

Nurse’s Notes
1:1,000EPI

Lidocaine
SpO2
Time

Atropine
HR

RR
BP

(pO2, pCO2, pH, Color, Mental Status, Temp.,

     

     

     

     

     

     
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)