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. 2016 Dec 23;8(12):e938. doi: 10.7759/cureus.938

Table 2. Mock code assessment form.

Mock Code Assessment Form Team Lead: Participants: Scenario: Facilitator(s): Date:  
Critical Performance Steps Check if correct
Recognizes client deterioration  

  • Assesses vital signs

  

  • Performs respiratory assessment

  

  • Recognizes need for help

  
Assessment and Activation  

  • Checks for responsiveness. Shakes shoulder, shouts patient’s name, and scans chest for movement (5–10 seconds)

  

  • Checks carotid pulse (minimum 5 seconds – maximum 10 seconds), if no pulse

  

  • Calls Code Blue or directs another rescuer to activate a Code Blue by calling 2000 on the internal phone line

  

  • Calls for help to bring crash cart or automated external defibrillator (AED) to bedside

  
CPR Skills  

  • Place patient in supine position with backboard and begin CPR

  

  • Proper hand placement (place on lower half of breast bone just above xiphoid process)

  

  • Compression rate of at least 100 to 120 compressions per minute with a ratio of 30:2

  

  • Adequate depth of at least 5 cm or 1/3 chest wall

  

  • Allow the chest to recoil completely after each compression

  

  • Changing compressors Q2 minutes or after five cycles of 30 compressions and two breaths

  

  • Minimize interruptions in compressions

  
 Ventilation  

  • Inserts oropharyngeal or nasopharyngeal airway (if required)

  

  • Positions mask properly on face

  

  • Effectively ventilates with a BVM device giving each breath over one second with visible chest rise

  

  • Gives proper ventilation rate and volume; gives two breaths after every 30 compressions

  
Defibrillation  

  • Place pads correctly on chest without interruption in chest compressions

  

  • Connects to defibrillator

  

  • Turns on LifePak 20 (Physio Control, Washington, USA) and gets rhythm

  

  • Clears before ‘analyze’ and ‘shock’

  

  • Immediately resumes CPR after shock delivery

  

  • Recognizes the two-minute mark to recheck pulse and rhythm

  

  • Administers appropriate drug(s) and doses when ordered

  
Team Leader  

  • Ensures high-quality CPR at all times

  

  • Assigns team member roles (intravenous, airway, defibrillator, documentation, compressor)

  

  • Looks for closed loop communication after directing tasks

  

  • SBAR format report given