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form Code Blue
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form Code Blue
dokumentasi kejadian code blue di Rumah Sakit...
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BundoKanduangNoor
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LAPORAN KEJADIAN CODE BLUE RSUD. Dr. ACHMAD MOCHTAR BUKITTINGGI
Tanggal: __________
waktu mulai : __________
Sistem Code Code Blue Aktif
☐ ya ☐tidak
Tipe Arrest:
Lokasi: __________
☐ "a ☐
☐ya ☐tidak
☐
Sirkulasi kemali
☐
tidak ada respon
Airway
$nitial:
u t k a &
☐
Spontan
☐
Apnea
Type of %entilation: %entilation: ☐
&aktu $ntuation: _________
'anual (entilation ag Tue si)e: ______________
Agonal
☐
*TT
Type:
☐
Assisted
☐
Trac!eostomy
$ntuation ole!: _________
☐
L'A
! a r a . n a n a k e T
/ g n u t n a , a m a r $ i d a n
waktu selesai: _______
n o i t a l l i r i f e . 0 s e l u o
☐
Pernafasan kemali
Circulatio!Car"iac
☐
n a s a f a n r e P
tidak
#ondisi :
☐ Cardiac ☐ Resp ☐ Resp/Cardiac
Patient Conscious at onset
Resusitasi er!asil
r e k a m e c a P
☐oral ☐nasal
+adi teraa:
☐"a ☐
$rama: _________
&aktu mulai R,P: __________ $rama -antung mulai R,P: _____________ &aktu mulai pasang infus: __________ lokasi: ________
no $% cat!: ________ __ ______
PEMANTAUAN DAN TERAPI
e n i r ! p e n i p *
e n i p o r t A
e n o r a d o i m A
e n i a c o d i L
n i s s e r p o s a %
m u i s e n g a ' e t a f l u S
d r a c o n e d A
e n i m a p o .
Catatan Perawat infus1 laor1 terapi1 dll0
#eluarga #eluarga pasien: ________________ _________________________ _________________ ________________ ___________ ___ Perawat Pelaksana: _________________ ___________________________ __________________ ________________ _______________ _______ .okter Code Blue : _________________ _________________________ __________________ _______ Perawat Pelaksana dokumentasi : _____________________ ________________________________________ ___________________ Pasien di kirim ke $2.: ☐ "a ☐ Tidak ,am: __________________ Pasien dikirim ke ruang perawatan : _________________ __ ,am : _______________
LAP3RA+ #*2$ATA+ #*2$ATA+
$.*+T$TAS PAS$*+ PAS$*+ +A'A : 4'4R
:
,*+$S #*LA'$+ : ALA'AT
:
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