Code WhiteEvaluation Form
Code WhiteEvaluation Form
Was the MET Call initiated prior to the Code Black?
If Comments / Remarks:
Were restraint measures (physical or chemical) in progress upon code team arrival?
If Comments / Remarks:
Was CODE WHITErecord completed?
If Comments / Remarks:
Was patient easily accessible to the code team?
If Comments / Remarks:
Were all Code Team members present?
If Comments / Remarks:
Was patient stabilized
If Comments / Remarks:
Was the primary care physician notified?
If Comments / Remarks:
Were there any damage to patient /staff/ equipment or hospital property?
If Comments / Remarks:
Did the code team follow protocol?
If Comments / Remarks:
Were there any other issues during the CODE WHITEthat we can improve upon?
If Comments / Remarks:
Was patient assigned nurse present during the Code?
If Comments / Remarks:
Was the Family notified?
If Comments / Remarks:
Were there processes that went particularly well and should be celebrated?
If Comments / Remarks: