Resuscitation Termination Protocol Checklist Form
Complete this checklist to document the resuscitation termination protocol review. All fields are designed for clear, concise documentation and task confirmation.
Patient/Case Identifier
*
Date and Time of Protocol Review
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location / Department
*
Responsible Clinician or Reviewer
*
Reason for Termination Review
*
Please Select
No return of spontaneous circulation
Prolonged resuscitation without improvement
Advanced directives / DNR present
Other (specify in notes)
Checklist Confirmation (select all that apply)
*
No shockable rhythm present
No reversible causes identified
Resuscitation duration meets protocol threshold
Team consensus achieved
Family informed (if appropriate)
Final Decision
*
Terminate resuscitation
Continue resuscitation
Post-Termination Actions (select all that apply)
Documentation completed
Family notified
Support services offered
Equipment accounted for
Additional Notes or Comments
Submit Checklist
Should be Empty: