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Anesthesiologist
30-45 minutes

Daily ICU Progress Note

The s10.ai ICU daily note template is an all-encompassing documentation resource tailored for anesthesiologists and critical care professionals. It streamlines the meticulous recording of patient status, encompassing diagnosis, progress, and examination findings throughout their Intensive Care Unit stay. Covering essential systems like respiratory, cardiovascular, and central nervous systems, this template ensures a comprehensive assessment of the patient's condition. Additionally, it features a dedicated plan section to delineate current and prospective management strategies. This template is perfect for ensuring precise and detailed records in high-acuity environments, thereby improving patient care and facilitating seamless communication among healthcare teams.

4,576 uses
4.9/5.0
A
Aisha Khan
Template Structure

Organized sections for comprehensive clinical documentation

[Date of evaluation]
Patient evaluated by [clinician's name and credentials]
[Patient's Name and Age followed by ICU duration in days.]
[Diagnosis and ICU admission rationale]
[Relevant background history (Provide detailed description, include only pertinent background history if specifically mentioned in the transcript or contextual notes.)]
Current issues list:
[Progress since admission list (Provide detailed description, include only progress since admission if specifically mentioned in the transcript or contextual notes)]
Resuscitation status (Provide detailed description, include only resuscitation status if specifically mentioned in the transcript or contextual notes.)
Examination:
Airway [Self-maintained, intubated, tracheostomy, or mask]
Breathing [Chest Auscultation
Ventilation Mode Fio2 PS PEEP
ABG Ph Po2 Pco2 Hco3
Chest X-ray or CT findings]
Circulation [CRT, MAP, BP HR Lactate
Peripheral pulses and edema
Inotrope or Vasopressors dose
Fluid balance
PPV/SVV
Echo/ECG findings
Trop T and BNP]
CNS. [Sedation type and dose
GCS or RASS Score
Delirium
Pupils
Movement response to painful stimulus
CT brain findings]
GIT. [Abdomen on examination
Bowel sounds present or absent
Any drains and output
Oral, NG, or TPN feed
NG Aspirate 4 hourly ok or high
Last Bowel motion on
Liver function tests and Amylase
Blood glucose levels
Insulin infusion]
Haematology [Hb platelet INR APTT
Anticoagulants dose and type]
Renal [Sodium Potassium Urea and Creatinine levels
Urine output and fluid balance per 24 hrs
Dialysis or Diuretics dose]
Sepsis [WCC and CRP levels and trends, temperature
Blood or urine culture results
COVID or Flu swabs
Any other cultures available
Antibiotics name and duration
Septic focus
Lines CVC/Vascath/Arterial line duration in situ]
[Peripheries, Wounds, or surgical incision sites healthy or infection suspected. (Provide detailed description, only if specifically mentioned in the transcript or contextual notes.)]
[Any pressure sores]
[Mobility]
Plan: (select as appropriate)
[Continue to ventilate or extubate.
Target Po2 and Pco2 and wean ventilation
Target MAP and wean inotropes/Vasopressors
Target RASS and wean sedation
Control delirium with
Laxatives or transition from TPN to NG/oral feed.
Target Hb and platelet count.
Target fluid balance, use fluids, albumin, diuretics, or dialysis
Start, stop, or adjust anticoagulant dosage as needed
De-escalate antibiotics.
Review drug cardex
Physio and mobilization
Investigation plan like ECG/CXR/CT/ specific bloods]
[Clinician's name]
Sample Clinical Note

Example of completed documentation using this template

1 November 2024
Patient evaluated by Dr. Tom Kol, Anaesthetist
John Doe, 45 years old, 5 days in ICU.
Diagnosis: Acute Respiratory Distress Syndrome (ARDS) secondary to pneumonia.
Background history: Type 2 Diabetes Mellitus, Hypertension.
Current issues list:
- Respiratory failure necessitating mechanical ventilation.
- Hemodynamic instability.
Progress since admission list:
- Enhanced oxygenation with decreased FiO2 needs.
- Stabilized blood pressure with reduced vasopressor support.
Resuscitation status: Full code.
Examination:
Airway: Intubated
Breathing:
- Chest Auscultation: Bilateral crackles
- Ventilation Mode: SIMV, FiO2 40%, PS 10, PEEP 5
- ABG: pH 7.35, Po2 85, Pco2 45, Hco3 24
- Chest X-ray: Bilateral infiltrates
Circulation:
- CRT: <2 seconds, MAP: 70 mmHg, BP: 110/70 mmHg, HR: 90 bpm, Lactate: 1.5 mmol/L
- Peripheral pulses: Present, no edema
- Inotrope: Noradrenaline 0.05 mcg/kg/min
- Fluid balance: Positive 500 ml
- Echo: Normal LV function
CNS:
- Sedation: Propofol 50 mg/hr
- RASS Score: -2
- Delirium: None
- Pupils: Equal and reactive
- Moving all limbs to painful stimulus
- CT brain: No acute changes
GIT:
- Abdomen: Soft, non-tender
- Bowel sounds: Present
- NG feed: Tolerating well
- Last bowel motion: 31 October 2024
- Liver function tests: Normal
- Blood glucose levels: 8 mmol/L
Haematology:
- Hb: 12 g/dL, Platelet: 150 x10^9/L, INR: 1.1, APTT: 30 seconds
- Anti coagulants: Enoxaparin 40 mg daily
Renal:
- Sodium: 140 mmol/L, Potassium: 4.0 mmol/L, Urea: 6 mmol/L, Creatinine: 80 µmol/L
- Urine output: 1500 ml/24 hrs
Sepsis:
- WCC: 12 x10^9/L, CRP: 50 mg/L
- Blood cultures: Negative
- Antibiotics: Meropenem, 3 days
Peripheries: No infection suspected.
Pressure sores: None
Mobility: Bedbound
Plan:
- Continue to ventilate, target Po2 > 80 mmHg
- Wean vasopressors
- Wean sedation, target RASS 0
- Laxatives to ensure bowel movement
- Maintain fluid balance
- Review drug cardex
- Physiotherapy and mobilisation
Dr. Tom Kol
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive ICU clinical template is designed to streamline patient management and enhance documentation accuracy for healthcare professionals. It includes detailed sections for patient review, diagnosis, and ICU admission reasons, ensuring all critical information is captured. The template covers current issues, resuscitation status, and thorough examinations across multiple systems, including airway, breathing, circulation, CNS, GIT, haematology, renal, and sepsis. It also addresses peripheries, wounds, pressure sores, and mobility, providing a holistic view of the patient's condition. The plan section allows for precise treatment adjustments, such as ventilation weaning, sedation management, fluid balance, and antibiotic de-escalation. By adopting this template, clinicians can improve patient outcomes, optimize care plans, and ensure comprehensive documentation, making it an essential tool for ICU settings.
Frequently Asked Questions

Common questions about this template and its usage

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Daily ICU Progress Note