Cardiac Arrest Documentation Form
Please complete this form to record details of a cardiac arrest event, including event specifics, response actions, treatments provided, and patient outcome.
Event Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Cardiac Arrest
*
Please Select
Hospital - Emergency Department
Hospital - Inpatient Ward
Out-of-Hospital - Home
Out-of-Hospital - Public Place
Out-of-Hospital - Work/Office
Other
Patient Age (years)
*
Patient Gender
*
Male
Female
Other/Unknown
Was the cardiac arrest witnessed?
*
Yes, by healthcare provider
Yes, by bystander
No
Unknown
Initial Cardiac Rhythm
*
Ventricular Fibrillation (VF)
Pulseless Ventricular Tachycardia (VT)
Asystole
Pulseless Electrical Activity (PEA)
Unknown
Was bystander CPR performed?
*
Yes, by healthcare provider
Yes, by layperson
No
Unknown
Defibrillation Provided?
*
Yes, AED used
Yes, manual defibrillator used
No
Not applicable
Airway Management Performed
*
Bag-valve-mask (BVM)
Oropharyngeal airway
Supraglottic airway
Endotracheal intubation
None
Other
Medications Administered During Resuscitation
*
Epinephrine
Amiodarone
Lidocaine
Magnesium sulfate
None
Other
Immediate Outcome of Resuscitation
*
Return of spontaneous circulation (ROSC)
Death
Ongoing resuscitation on transfer
Unknown
Submit Documentation
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