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APPENDIX 7
RESUSCITATION EVENT REPORT FORM
SECTION 1: PATIENT DETAILS (complete or affix patient label to ALL copies)
Name:
NHS No.:
AFFIX PATIENT LABEL HERE IF
AVAILABLE
(Or complete box to right if not available)
Date of Birth: __/__/__
Gender: M/F
Reason For Admisson (if in an inpatient area):
SECTION 2: INITIAL EVENT DETAILS
Date of Event:___ / ___ / ___
Type of arrest:
Time of Event (24 hr clock): ____:____
Respiratory only
□
□
Cardiac
YES
□
NO
□
□
NO
□
Time of Arrest (if different from above): ____:____
Location of the Event ……………………………………………..
Ambulance Called:
Witnessed? YES
Precipitating event i.e. chest pain, head injury etc.........................................
If no, please state reason:……………………………………………………………………………….
Time Ambulance Called: ____:____
Time Ambulance Arrived: ____:____
CPR in progress on ambulance arrival:
YES
□
NO
Time Ambulance Departed: ____:____
□
SECTION 3: BASIC LIFE SUPPORT MANAGEMENT – Please indicate which were used.
AIRWAY MANAGEMENT :
Head Tilt Chin Lift/ Jaw Thrust
□
Suction
□
iGel
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Oropharyngeal Airway
□
Nasopharyngeal Airway
□
BREATHING:
Mouth to Mouth □
Face Shield
□
Pocket mask
□
□
Bag Valve Mask
Oxygen
□
SECTION 4: DEFIBRILLATION
Time Defibrillator with Patient: ____:____
Time of 1st Analysis: ____:____
Type of Defibrillator:
Initial Rhythm: Shockable
Time First Cardiac Arrest Drug Administered: ____:____
□
AED
□
Non-Shockable
Manual
□
□
No. of Shocks Delivered:
Total no. of cycles of CPR:
SECTION 5: ANY OTHER INTERVENTIONS
Autopulse
□
Time : ___/___
Cannulation
□
Time : ___/___
Drug Therapy
□
Fluid Therapy
□
IF DRUGS AND/ OR FLUIDS HAVE BEEN ADMINISTERED, PLEASE LIST BELOW:
TIME
____:____
____:____
____:____
____:____
____:____
____:____
DRUG/ FLUID
DOSE
ROUTE
COMMENTS
None
□
SECTION 6: POST EVENT – what was the reason resuscitation was stopped?
Patient deceased
Patient transferred
□
□
Return of spontaneous circulation
□
If patient was transferred, was CPR in progress
YES
□
NO
□
If patient transferred, where was the patient transferred to:
If patient transferred, what was the outcome :
Other
□
Dead on arrival
□
Admitted
□
Unknown
□
(please state):…………………………………………………………………………………..
SECTION 7: ANY OTHER RELEVANT INFORMATION (i.e. additional drugs administered, other interventions carried out, other individuals in
attendance etc.)
SECTION 8: TO BE COMPLETED BY A MEMBER OF THE TEAM
Name of person completing the form:
Designation of the person completing the form:
Signature of the person completing the form:
__________________________
Who else was present during the event:
NAME: _____________________
POSITION: __________________
NAME: _____________________
POSITION: __________________
NAME: _____________________
POSITION: __________________
NAME: _____________________
POSITION: __________________
NAME: _____________________
POSITION: __________________
NAME: _____________________
POSITION: __________________
DATE FORM COMPLETED: ___ / ___ / ___
NEXT STEPS
Have you remembered to:
Initial
1. Send a stock replacement form to Openhouse if the Medical Resus bag has been used?
□
____
2. Replenished and checked the resuscitation trolley (LNFH and ECT Suites only)?
□
____
2. Carried out a defibrillator battery test on X Series ONLY (as per manufacturers instructions)?
□
____
3. Updated the patients notes?
□
____
4. Completed an online incident form (Ulysses)
□
____
5. Informed your manager and/ or any other relevant other?
□
____
6. Debrief (where as soon as practically possible)?
□
____
7. Place a photocopy of this form in the patient notes
□
____
8. Send completed form to the Resuscitation Officers at LEaD, Tatchbury Mount
□
____