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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 Please answer the following questions with respect to the RRT Event. The Primary Nurse of the patient should complete this form and return it within 24 hours Question Disagree Strongly Slightly Neutral Agree 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. 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. The Primary Nurse of the patient should complete this form and return it within 24 hours Question Disagree Strongly Slightly Neutral Agree 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. 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. 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. 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. managing the patient s care. The RRT helped me to learn something new or something I should have done. 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.

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