Rapid Response and Code Blue Records: What to Check

A rapid response team (RRT) call brings critical care staff to a patient who is deteriorating; a code blue is called when a patient arrests or is about to. The records of both show what the team found and did. For the nursing case, though, the most important questions are usually about the hours before the call: when the warning signs appeared, whether the facility's criteria for calling were met earlier, and why no one called. The code record then answers a second question: whether the resuscitation itself followed the expected sequence.

Rapid response records

Most hospitals have a rapid response policy that lists activation criteria. These usually cover acute changes in heart rate, respiratory rate, blood pressure, oxygen saturation, level of consciousness or urine output, plus a criterion that lets any staff member call when worried about the patient. Many hospitals also let families call. Many use an early warning score, such as MEWS or NEWS2, calculated from vital signs, where a set score prompts a call or a provider notification.

An RRT record usually shows:

• Who called, why, and the time of the call
• When the team arrived
• The team's assessment, interventions and orders
• The outcome: stayed on the unit, moved to a higher level of care, code status discussed
• Recommendations for follow-up monitoring

Some facilities document RRTs on a dedicated form or EHR event record, others in a free-text note. Ask how this facility does it.

Code blue records

The code record (also called the resuscitation record or code sheet) is kept by a designated recorder during the event. It should capture:

• The time the arrest was recognized, the code was called and CPR began
• The initial rhythm and each rhythm check
• Each defibrillation, with time and energy
• Each medication, with dose and time
• Airway management and how placement was confirmed
• Return of spontaneous circulation, transfer, or time of death
• The team members present

Resuscitation is measured against the American Heart Association's Advanced Cardiovascular Life Support (ACLS) guidelines, and pediatric resuscitation against Pediatric Advanced Life Support (PALS). Those guidelines set out the expected sequence: for example, early defibrillation for a shockable rhythm, and epinephrine every 3 to 5 minutes during cardiac arrest.

The defibrillator or monitor download is often the best evidence of what really happened. Many devices store the ECG and shock times, and some models also store CPR quality data. That data sits on the device or in separate software, not in the chart, and it can be overwritten or cleared. Preserve it early.

What a nurse reviewer checks before the call

• Criteria met earlier. Vital signs, an early warning score or a change in mental status that met the RRT criteria hours before anyone called. This is the core of most failure to rescue cases. See Failure to Rescue: The Nursing Timeline.
• Notifications instead of a rapid response. Repeated "provider notified" entries while the patient met criteria and the policy called for an RRT.
• Reassessment frequency. Whether checks became more frequent as the patient worsened, or stayed at routine intervals.
• Monitoring status. Was the patient on telemetry or continuous pulse oximetry, and were the alarms active? See Telemetry Alarm Records in Cardiac Monitoring Cases.
• The last time anyone saw the patient. For an unwitnessed arrest, the gap between the last documented assessment and discovery is often the key fact.
• What the handoff said. Many deteriorations span a shift change. See Nurse Handoff Failures: What SBAR Records Show.

What a nurse reviewer checks after the RRT

• Whether the team's recommendations (vital sign frequency, labs, a recheck) were carried out.
• Whether a patient who stayed on the unit met criteria again, and whether anyone called again.
• Whether a recommended transfer happened, and how long it took.

What a nurse reviewer checks in the code record

• Time to CPR and to the first shock, from the recorder's notes and the device download.
• Gaps in the recorder's timeline, or medication times that don't fit the guideline sequence.
• Rhythm documentation against the download. The device data may not show what the record says.
• Code status. Was the patient's code status known and followed? Was a DNR order honored, or was a full-code patient left without a full response?
• Equipment. Was the crash cart stocked and checked, and did the equipment work? Crash cart check logs are separate records.

What to request

1. The RRT record and the code record, both the scanned paper original and any EHR version
2. The defibrillator and monitor event download, with the device's clock time noted
3. Telemetry strips, central station alarm history and pulse oximetry data
4. Early warning score data, if the hospital uses one
5. Policies on rapid response activation, code blue, early warning score response, monitoring and chain of command
6. Crash cart check logs for the unit and date
7. Staffing and assignment records for the shift

Code and RRT committee reviews are often claimed as peer review or quality improvement material. Whether they are protected varies by state, so check the rules that govern your case. The records checklist for failure to rescue cases lists the chart records to request alongside these.

Pitfalls

• Treating code sheet times as exact. Recorders write fast and often reconstruct times afterward. The device download is usually more reliable, but its clock may not match the hospital's.
• Missing the paper record. Code sheets are often completed on paper and scanned into a media section that standard productions leave out.
• Looking only at the code. A well-run resuscitation after hours of unaddressed decline is still a failure to rescue case.
• Over-reading late notes. Nurses document after a code, and that is expected. Look harder only when a late note describes the hours before the event.

Code performance and causation questions usually need both nursing and physician review. A standard of care review from a nurse with ICU and critical care experience covers the nursing side.

Next step

Post a failure to rescue case for a chronology: a critical care nurse lines up the warning signs, the calls and the response minute by minute. Records stay private until you hire.

General information for legal professionals, not legal advice. Rules and deadlines vary by state; check the statute and local rules that govern your case.