Rapid Response Team (Rrt) Evaluation Form printable pdf download

Queen’s Medical Center, Honolulu

Rapid Response Team (RRT) Evaluation Form

Date of Event: ______Time of Event: _______ Place of Event (Dept/Unit of Patient):______________

Patient Name:___________

Medical Record #: ____________

Acct #: _________________

(6 digit)

(8 digit)

Please answer the following questions with respect to the RRT Event.

Χ The Primary Nurse of the patient should complete this form and return it within 24 hours

Χ Please answer each question and mark your responses with an “X” when appropriate

Disagree

Neutral

Agree

Question

Strongly

Slightly

slightly

Strongly

The RRT arrived in a timely manner

The RRT nurse was knowledgeable and efficient in assessing

and implementing care needs

The RRT respiratory care therapist was knowledgeable and

efficient in assessing and implementing care needs.

Communication to and from the RRT nurse and/or respiratory

care therapist was effective in facilitating the delivery of care.

The RRT was courteous and helpful.

Patient outcome was improved because of RRTassistance.

I worked collaboratively with the RRT and the attending

physician/resident.

In working with the RRT I feel more comfortable and confident

in managing patient in pre or potential crisis.

The RRT helped me to learn something new or something I

should have done.

The RRT helped me to see or understand the “big picture” on

managing the patient’s care.

EDUCATION: (Briefly describe what you learned)

PROCESS IMPROVEMENT: (Briefly describe a change in a patient care process that could help improve patient care)

ADDITIONAL COMMENTS:

Primary Nurse (Print name)__________________________ (Signature) _________________________

Please return completed form to Nurse Manager, QET 4C within 24 hours of event.

Adapted from Missouri Baptist, Memphis by Queen’s Medical Center. Reprinted by permission

Rapid Response Team (Rrt) Evaluation Form