CPR Closed-Loop Communication Checklist Form
Document communication checks and team performance during a CPR event using this checklist.
Date and Time of CPR Event
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Event
*
Observer Name
*
Team Roles Clearly Assigned and Announced
*
Yes
No
Partially
Closed-Loop Communication (Call-back/Read-back) Consistently Used
*
Yes
No
Partially
Instructions Delivered Clearly and Understood by Team
*
Yes
No
Partially
Tasks Confirmed as Completed by Assigned Team Members
*
Yes
No
Partially
Any Missed or Unclear Communication Noted
Overall Outcome/Status of CPR Event
*
Please Select
Resuscitation Successful
Resuscitation Unsuccessful
Ongoing
Submit Checklist
Should be Empty: