Healthcare Rapid Response Form

Healthcare Rapid Response Form

Patient Information

Date of Birth:    Gender:

Phone:    Emergency Contact:

Emergency Contact Relationship:    Emergency Contact Phone:

Insurance Information

Policy/ID Number:    Group Number:

Medical History / Current Status

Incident Details

Incident Date:    Incident Time:

Vital Signs at Time of Response

Temperature:    Heart Rate:

Blood Pressure:    Respiratory Rate:

Oxygen Saturation (SpO2):

Assessment and Interventions

Interventions performed (check all that apply):

Oxygen administered    Nebulizer    IV access established

Medication administered    Medication name/dose/time:

CPR performed    Defibrillation    Endotracheal intubation

Notification and Disposition

Primary physician notified: Yes    No

Physician name notified:    Time notified:

Disposition (select one):

Observed on site    Transferred to higher level of care    Discharged home

Transfer time:    Receiving provider contact:

Advance Directives / Code Status

Code status: Full Code    Do Not Resuscitate    Limited Interventions

Legal Authorization and Acknowledgement

By signing below, I acknowledge that the rapid response team evaluated and treated me or the patient named above. I authorize the release and disclosure of relevant medical information to members of the rapid response team and to receiving facilities or treating providers as necessary for emergency care and transfer. I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand that I may withdraw this authorization in writing, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on the date indicated below unless an earlier revocation is submitted in writing.

Authorization expires on:

Department / Unit:    Incident Report # (if assigned):

Sign Now