Documenting Resuscitation Events
Creates structured, time-stamped code documentation that captures every intervention, rhythm change, medication administration, and team action during cardiac arrest resuscitation per AHA/ACLS standards.
Why This Skill Exists
Resuscitation documentation is among the most legally scrutinized records in emergency medicine. In wrongful death litigation, plaintiff attorneys dissect every timestamp, every drug dose, and every gap between interventions. Incomplete code sheets are cited in over 40% of cardiac arrest malpractice cases as evidence of substandard care—even when the clinical care itself was appropriate. Beyond legal risk, accurate code documentation drives quality improvement: Utstein-style data collection enables meaningful survival-to-discharge analysis and CPR quality benchmarking.
AHA 2020 guidelines emphasize that high-quality CPR metrics (compression rate 100-120/min, depth 5-6 cm, full recoil, minimal interruptions) should be documented in real time. Facilities that rigorously track these metrics show 15-25% improvement in ROSC rates over two years.
Checkpoint A: Pre-Draft Intake (Mandatory)
Before constructing the resuscitation record, confirm:
- What was the exact time the code was called (or arrest discovered)?
- Was the arrest witnessed or unwitnessed? If witnessed, by whom?
- What was the initial rhythm on the monitor (VF, pVT, PEA, asystole)?
- Were there any advance directives, POLST, or DNR orders in the chart?
- What was the patient's pre-arrest status (alert, intubated, on vasopressors, post-operative)?
- Who was designated as the code team leader?
- Was the event in-hospital or was the patient brought in during active CPR (OHCA)?
- For out-of-hospital cardiac arrest: What was the EMS-reported downtime, bystander CPR status, and number of pre-hospital shocks delivered?
Documents to Request
- Pre-arrest medical record and medication administration record
- Advance directive or POLST form if available
- EMS run sheet (for out-of-hospital arrests)
- Defibrillator download data (biphasic waveform, shock energy, CPR metrics)
- Code sheet or code narrator log
- Nursing flow sheet from the code period
- Pharmacy verification of medications drawn and administered
- Post-ROSC or termination-of-efforts order
- Family notification documentation
Step 1: Pre-Arrest Baseline Documentation
Record the patient's status immediately before the arrest:
| Element |
Required Data |
| Location |
Unit, room number, in-transport, procedural area |
| Pre-arrest rhythm |
Normal sinus, atrial fibrillation, monitored/unmonitored |
| Pre-arrest vitals |
Last recorded BP, HR, RR, SpO2, temperature |
| Pre-arrest mental status |
GCS score or alert/verbal/pain/unresponsive |
| Active medications |
Vasopressors, antiarrhythmics, sedation infusions |
| IV access |
Existing lines, gauge, location |
| Airway status |
Room air, nasal cannula, BiPAP, intubated |
| Code status |
Full code, DNR-A, DNR-B, comfort measures |
Step 2: Arrest Recognition and Initial Response Timeline
Document with times accurate to the minute:
- Time zero (T+0): Arrest recognized—who discovered, how (witnessed collapse, monitor alarm, routine check)
- T+0 to T+1 min: CPR initiated—by whom, on what surface (backboard placed?)
- T+1 to T+2 min: Code called—overhead page, code button, rapid response escalation
- T+2 min: Defibrillator/monitor attached—initial rhythm identified and documented
- First shock (if VF/pVT): Time, energy level (biphasic 120-200J per device), response
For each CPR cycle (2-minute intervals), document:
- Compressor identity and rotation times
- Any pauses >10 seconds with reason (rhythm check, intubation attempt, pulse check)
- End-tidal CO2 reading if capnography in use (target >10 mmHg for effective CPR; >40 mmHg may indicate ROSC)
Step 3: Medication Administration Log
Record every medication with six-rights verification:
| Medication |
Standard Dose |
Route |
Timing per ACLS |
| Epinephrine |
1 mg (1:10,000) |
IV/IO |
Every 3-5 minutes |
| Amiodarone |
300 mg first dose, 150 mg second |
IV/IO |
After 3rd shock for refractory VF/pVT |
| Lidocaine |
1-1.5 mg/kg first, 0.5-0.75 mg/kg subsequent |
IV/IO |
Alternative to amiodarone |
| Sodium bicarbonate |
1 mEq/kg |
IV/IO |
For known hyperkalemia or TCA overdose |
| Calcium chloride |
1-2 g (10% solution) |
IV central preferred |
For hyperkalemia, calcium channel blocker OD |
| Magnesium sulfate |
1-2 g |
IV/IO |
For torsades de pointes |
| Lipid emulsion 20% |
1.5 mL/kg bolus |
IV |
For local anesthetic systemic toxicity |
For each dose: exact time given, who drew and who administered, route (peripheral IV, IO, central line), and any complications (extravasation, line malfunction).
Step 4: Rhythm Analysis and Defibrillation Record
Document each rhythm check at 2-minute intervals:
- Time of rhythm check
- Rhythm identified (VF, pVT, PEA, asystole, organized rhythm with pulse)
- Action taken (shock delivered, resume CPR, pulse check)
- If shock: energy delivered, device manufacturer/model, pad placement (anterolateral vs. anteroposterior)
- Post-shock rhythm at next check
- Total number of shocks delivered
Key documentation for quality: Note if defibrillator data download was performed post-event—this provides objective CPR quality metrics (compression rate, depth, fraction) that supplement the written record.
Step 5: Airway Management Documentation
| Airway Action |
Time |
Provider |
Method |
Confirmation |
| BVM ventilation initiated |
|
|
OPA/NPA size, 2-hand technique |
Chest rise observed |
| Supraglottic airway placed |
|
|
Device type and size (iGel, King LT) |
ETCO2 waveform confirmed |
| Endotracheal intubation |
|
|
Blade type/size, tube size, depth at teeth |
ETCO2 waveform + bilateral breath sounds |
| Surgical airway |
|
|
Cricothyrotomy vs. tracheostomy |
ETCO2 confirmed |
Document number of attempts per provider (ACLS recommends limiting laryngoscopy to <10 seconds to minimize CPR interruption). Record any use of video laryngoscopy versus direct.
Step 6: ROSC or Termination Documentation
If ROSC achieved:
- Time of ROSC (first sustained organized rhythm with palpable pulse >30 seconds)
- Post-ROSC vitals: BP, HR, rhythm, SpO2, ETCO2
- Post-ROSC interventions: targeted temperature management (TTM) at 32-36 degrees C, vasopressor titration, 12-lead ECG for STEMI evaluation, arterial blood gas
- Post-ROSC neurologic status: GCS, pupillary response, presence of spontaneous movement
- Disposition: ICU admission, cardiac catheterization lab, continued ED management
If efforts terminated:
- Time of death pronounced
- Total resuscitation duration
- Physician who made the termination decision
- Clinical rationale (e.g., refractory asystole >20 minutes, no ETCO2 >10 despite quality CPR, known terminal condition)
- Family notification: by whom, time, persons present
- Medical examiner notification if required by jurisdiction
- Organ/tissue donation referral per protocol
Checkpoint B: Post-Draft Alignment (Mandatory)
Before finalizing the resuscitation record, verify:
- Are all timestamps internally consistent (no interventions documented before the code was called)?
- Does the medication log show ACLS-compliant dosing intervals (epinephrine every 3-5 min)?
- Is CPR quality documented (compression rate, depth if monitor data available, interruptions)?
- Does the record identify the code team leader and each team member's role?
- Is the outcome clearly documented (ROSC with disposition or death with time and notification)?
Quality Audit
| # |
Criterion |
Pass/Fail |
| 1 |
Exact time of arrest recognition documented |
|
| 2 |
Initial rhythm clearly identified and recorded |
|
| 3 |
CPR start time within 1 minute of recognition for in-hospital |
|
| 4 |
First defibrillation within 3 minutes for shockable rhythms |
|
| 5 |
Epinephrine timing documented with 3-5 minute intervals |
|
| 6 |
All medications include dose, route, time, and administrator |
|
| 7 |
Rhythm documented at each 2-minute CPR cycle |
|
| 8 |
Airway management attempts numbered with times and providers |
|
| 9 |
H's and T's (reversible causes) evaluated and documented |
|
| 10 |
ETCO2 values recorded if capnography used |
|
| 11 |
Post-ROSC 12-lead ECG obtained within 15 minutes |
|
| 12 |
Post-ROSC TTM consideration documented |
|
| 13 |
Family notification time and method recorded |
|
| 14 |
Defibrillator download requested/obtained |
|
Guidelines
- Use Utstein-style reporting elements for all cardiac arrest documentation to enable benchmarking and registry participation (CARES, Get With The Guidelines)
- Designate a code recorder at the start of every resuscitation—this person does not perform clinical tasks but captures real-time data
- Document H's and T's assessment: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis (pulmonary), Thrombosis (coronary)
- CPR fraction target >80%: Document any interruption >10 seconds with explicit reason
- Do not alter timestamps retroactively—if a time is uncertain, record as approximate with a notation
- Pediatric arrests require weight-based dosing documentation: use Broselow tape color or actual weight, document which reference was used
- For medical-legal protection, the code sheet is a contemporaneous medical record—ensure it matches the defibrillator data download and nursing notes exactly
- Post-event debriefing should be documented separately, noting any system issues (equipment failures, delayed response) for quality improvement without creating discoverable self-critical analysis
1---2name: documenting-resuscitation-events3description: Creates structured code documentation with timestamps, interventions, and ROSC criteria. Use when documenting cardiac arrests, recording resuscitation timelines, or completing code sheets.4---5
6# Documenting Resuscitation Events
7
8Creates structured, time-stamped code documentation that captures every intervention, rhythm change, medication administration, and team action during cardiac arrest resuscitation per AHA/ACLS standards.
9
10## Why This Skill Exists
11
12Resuscitation documentation is among the most legally scrutinized records in emergency medicine. In wrongful death litigation, plaintiff attorneys dissect every timestamp, every drug dose, and every gap between interventions. Incomplete code sheets are cited in over 40% of cardiac arrest malpractice cases as evidence of substandard care—even when the clinical care itself was appropriate. Beyond legal risk, accurate code documentation drives quality improvement: Utstein-style data collection enables meaningful survival-to-discharge analysis and CPR quality benchmarking.
13
14AHA 2020 guidelines emphasize that high-quality CPR metrics (compression rate 100-120/min, depth 5-6 cm, full recoil, minimal interruptions) should be documented in real time. Facilities that rigorously track these metrics show 15-25% improvement in ROSC rates over two years.
15
16---
17
18## Checkpoint A: Pre-Draft Intake (Mandatory)
19
20Before constructing the resuscitation record, confirm:
21
221. What was the exact time the code was called (or arrest discovered)?
232. Was the arrest witnessed or unwitnessed? If witnessed, by whom?
243. What was the initial rhythm on the monitor (VF, pVT, PEA, asystole)?
254. Were there any advance directives, POLST, or DNR orders in the chart?
265. What was the patient's pre-arrest status (alert, intubated, on vasopressors, post-operative)?
276. Who was designated as the code team leader?
287. Was the event in-hospital or was the patient brought in during active CPR (OHCA)?
298. For out-of-hospital cardiac arrest: What was the EMS-reported downtime, bystander CPR status, and number of pre-hospital shocks delivered?
30
31### Documents to Request
32
33- Pre-arrest medical record and medication administration record
34- Advance directive or POLST form if available
35- EMS run sheet (for out-of-hospital arrests)
36- Defibrillator download data (biphasic waveform, shock energy, CPR metrics)
37- Code sheet or code narrator log
38- Nursing flow sheet from the code period
39- Pharmacy verification of medications drawn and administered
40- Post-ROSC or termination-of-efforts order
41- Family notification documentation
42
43---
44
45## Step 1: Pre-Arrest Baseline Documentation
46
47Record the patient's status immediately before the arrest:
48
49| Element | Required Data |
50|---|---|
51| Location | Unit, room number, in-transport, procedural area |
52| Pre-arrest rhythm | Normal sinus, atrial fibrillation, monitored/unmonitored |
53| Pre-arrest vitals | Last recorded BP, HR, RR, SpO2, temperature |
54| Pre-arrest mental status | GCS score or alert/verbal/pain/unresponsive |
55| Active medications | Vasopressors, antiarrhythmics, sedation infusions |
56| IV access | Existing lines, gauge, location |
57| Airway status | Room air, nasal cannula, BiPAP, intubated |
58| Code status | Full code, DNR-A, DNR-B, comfort measures |
59
60---
61
62## Step 2: Arrest Recognition and Initial Response Timeline
63
64Document with times accurate to the minute:
65
661. **Time zero (T+0)**: Arrest recognized—who discovered, how (witnessed collapse, monitor alarm, routine check)
672. **T+0 to T+1 min**: CPR initiated—by whom, on what surface (backboard placed?)
683. **T+1 to T+2 min**: Code called—overhead page, code button, rapid response escalation
694. **T+2 min**: Defibrillator/monitor attached—initial rhythm identified and documented
705. **First shock** (if VF/pVT): Time, energy level (biphasic 120-200J per device), response
71
72For each CPR cycle (2-minute intervals), document:
73- Compressor identity and rotation times
74- Any pauses >10 seconds with reason (rhythm check, intubation attempt, pulse check)
75- End-tidal CO2 reading if capnography in use (target >10 mmHg for effective CPR; >40 mmHg may indicate ROSC)
76
77---
78
79## Step 3: Medication Administration Log
80
81Record every medication with six-rights verification:
82
83| Medication | Standard Dose | Route | Timing per ACLS |
84|---|---|---|---|
85| Epinephrine | 1 mg (1:10,000) | IV/IO | Every 3-5 minutes |
86| Amiodarone | 300 mg first dose, 150 mg second | IV/IO | After 3rd shock for refractory VF/pVT |
87| Lidocaine | 1-1.5 mg/kg first, 0.5-0.75 mg/kg subsequent | IV/IO | Alternative to amiodarone |
88| Sodium bicarbonate | 1 mEq/kg | IV/IO | For known hyperkalemia or TCA overdose |
89| Calcium chloride | 1-2 g (10% solution) | IV central preferred | For hyperkalemia, calcium channel blocker OD |
90| Magnesium sulfate | 1-2 g | IV/IO | For torsades de pointes |
91| Lipid emulsion 20% | 1.5 mL/kg bolus | IV | For local anesthetic systemic toxicity |
92
93For each dose: exact time given, who drew and who administered, route (peripheral IV, IO, central line), and any complications (extravasation, line malfunction).
94
95---
96
97## Step 4: Rhythm Analysis and Defibrillation Record
98
99Document each rhythm check at 2-minute intervals:
100
1011. Time of rhythm check
1022. Rhythm identified (VF, pVT, PEA, asystole, organized rhythm with pulse)
1033. Action taken (shock delivered, resume CPR, pulse check)
1044. If shock: energy delivered, device manufacturer/model, pad placement (anterolateral vs. anteroposterior)
1055. Post-shock rhythm at next check
1066. Total number of shocks delivered
107
108**Key documentation for quality**: Note if defibrillator data download was performed post-event—this provides objective CPR quality metrics (compression rate, depth, fraction) that supplement the written record.
109
110---
111
112## Step 5: Airway Management Documentation
113
114| Airway Action | Time | Provider | Method | Confirmation |
115|---|---|---|---|---|
116| BVM ventilation initiated | | | OPA/NPA size, 2-hand technique | Chest rise observed |
117| Supraglottic airway placed | | | Device type and size (iGel, King LT) | ETCO2 waveform confirmed |
118| Endotracheal intubation | | | Blade type/size, tube size, depth at teeth | ETCO2 waveform + bilateral breath sounds |
119| Surgical airway | | | Cricothyrotomy vs. tracheostomy | ETCO2 confirmed |
120
121Document number of attempts per provider (ACLS recommends limiting laryngoscopy to <10 seconds to minimize CPR interruption). Record any use of video laryngoscopy versus direct.
122
123---
124
125## Step 6: ROSC or Termination Documentation
126
127**If ROSC achieved:**
1281. Time of ROSC (first sustained organized rhythm with palpable pulse >30 seconds)
1292. Post-ROSC vitals: BP, HR, rhythm, SpO2, ETCO2
1303. Post-ROSC interventions: targeted temperature management (TTM) at 32-36 degrees C, vasopressor titration, 12-lead ECG for STEMI evaluation, arterial blood gas
1314. Post-ROSC neurologic status: GCS, pupillary response, presence of spontaneous movement
1325. Disposition: ICU admission, cardiac catheterization lab, continued ED management
133
134**If efforts terminated:**
1351. Time of death pronounced
1362. Total resuscitation duration
1373. Physician who made the termination decision
1384. Clinical rationale (e.g., refractory asystole >20 minutes, no ETCO2 >10 despite quality CPR, known terminal condition)
1395. Family notification: by whom, time, persons present
1406. Medical examiner notification if required by jurisdiction
1417. Organ/tissue donation referral per protocol
142
143---
144
145## Checkpoint B: Post-Draft Alignment (Mandatory)
146
147Before finalizing the resuscitation record, verify:
148
1491. Are all timestamps internally consistent (no interventions documented before the code was called)?
1502. Does the medication log show ACLS-compliant dosing intervals (epinephrine every 3-5 min)?
1513. Is CPR quality documented (compression rate, depth if monitor data available, interruptions)?
1524. Does the record identify the code team leader and each team member's role?
1535. Is the outcome clearly documented (ROSC with disposition or death with time and notification)?
154
155---
156
157## Quality Audit
158
159| # | Criterion | Pass/Fail |
160|---|---|---|
161| 1 | Exact time of arrest recognition documented | |
162| 2 | Initial rhythm clearly identified and recorded | |
163| 3 | CPR start time within 1 minute of recognition for in-hospital | |
164| 4 | First defibrillation within 3 minutes for shockable rhythms | |
165| 5 | Epinephrine timing documented with 3-5 minute intervals | |
166| 6 | All medications include dose, route, time, and administrator | |
167| 7 | Rhythm documented at each 2-minute CPR cycle | |
168| 8 | Airway management attempts numbered with times and providers | |
169| 9 | H's and T's (reversible causes) evaluated and documented | |
170| 10 | ETCO2 values recorded if capnography used | |
171| 11 | Post-ROSC 12-lead ECG obtained within 15 minutes | |
172| 12 | Post-ROSC TTM consideration documented | |
173| 13 | Family notification time and method recorded | |
174| 14 | Defibrillator download requested/obtained | |
175
176---
177
178## Guidelines
179
1801. **Use Utstein-style reporting** elements for all cardiac arrest documentation to enable benchmarking and registry participation (CARES, Get With The Guidelines)
1812. **Designate a code recorder** at the start of every resuscitation—this person does not perform clinical tasks but captures real-time data
1823. **Document H's and T's assessment**: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis (pulmonary), Thrombosis (coronary)
1834. **CPR fraction target >80%**: Document any interruption >10 seconds with explicit reason
1845. **Do not alter timestamps retroactively**—if a time is uncertain, record as approximate with a notation
1856. **Pediatric arrests** require weight-based dosing documentation: use Broselow tape color or actual weight, document which reference was used
1867. **For medical-legal protection**, the code sheet is a contemporaneous medical record—ensure it matches the defibrillator data download and nursing notes exactly
1878. **Post-event debriefing** should be documented separately, noting any system issues (equipment failures, delayed response) for quality improvement without creating discoverable self-critical analysis
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