NOTE: IT IS NOT POSSIBLE TO MAKE A 'STANDARD ICU NOTE'. THE FORM BELOW SHOULD SERVE TO GIVE AN IDEA OF THE FORMAT ONLY, BUT THE CONTENTS DIFFER WITH PATIENTS. THE ICU PATIENTS ARE ALL DIFFERENT, EVEN THOSE WITH THE SAME DIAGNOSES. THE SITUATIONS ARE VERY COMPLEX AND THE DIAGNOSTIC/THERAPEUTIC TESTS AND MANEUVERS MULTIPLE.
YOU MUST TAYLOR YOUR NOTE TO YOUR PATIENT'S PROBLEMS AND ADD RELEVANT INFORMATION UNDER EACH ORGAN SYSTEM AS NECESSARY. THE NOTE IS FOR YOU, THE CONSULTANT AND FELLOW WORKERS TO UNDERSTAND: MAKE IT LEGIBLE, THOROUGH, LOGICAL AND RELEVANT. LET IT TELL THE READER WHAT WAS HAPPENING, WHAT YOU DID OR PLAN TO DO, AND WHAT WAS THE RESULT OF EACH STEP.
SHARE YOUR NOTE VERBALLY WITH YOUR COWORKERS...UNLESS YOU ARE GOD AND PLAN TO LIVE IN THE ICU FOR THE REST OF YOUR LIFE.
GOT THE IDEA? OK...READ ON...
It is now about noon and you have finished rounds. The team knows what to do. You sigh in relief. You are there, sitting in the ICU station, pen ready...Keeping an eye on the monitor and your ears on their beeps...Respiratory therapists, nurses, residents and consultants are walking all around the place. Your coffee got cold and your donut stiff. In the midst of this, you must write...Are't you glad there is a format? This is how it goes...
S.Summarize patient's comments, if any, or his family's.
Neurologic: Enter a brief but informative report of the neurologic status of the patient. You may want to add the Glasgow Coma Scale or the Hunt and Hess Scale (for subarachnoid hemorrhage). In spinal cord injury patients, follow the "level" or sensory or motor loss and the status of reflexes.
Cardiovascular: Describe your auscultation, peripheral pulses and skin details (color, feel and temp). Add HR (with appreciation of the rhythm), BP, MAP, hemodynamic data (eg. PCWP, PAP, SVR, CI, etc). Enter the description of the EKG, monitor strip or any other relevant test (eg. echocardiogram, cardiac cath, etc). Add cardiac enzymes here if you have them, of course.
Respiratory: Enter description of respiratory pattern, auscultation findings and level of effort. Then, enter RR, form of ventilation (mechanical or spontaneous). Enter ventilator settings and mode. Add arterial blood gases values and calculations. Did you see any important numbers in the RT's ventilator sheets? HOw was the PIP? Enter the description of the chest X-ray and any other diagnostic test (eg. bedside measurement of vital capacity, inspiratory effort, or the results of the VQ scan or venous doppler of the lower extremities for example). Was there a leak in the chest tube?
Renal/Fluids: Describe skin feel and turgor, hydration of the mucosae, etc. Enter hemodynamic data such as CVP or PCWP. Jot down the type of fluids being given, the rate of administration and describe any additives in the fluids (eg. phosphorus supplements). Write down the intake and output of the last 24 hours; after considering the insensible losses, calculate the net output/input. Data such as the electrolytes, cretinine, BUN, and myoglobin (if relevant) are part of this section. Add any relevant test result (eg. renal ultrasound test).
Gastrointestinal/Nutrition: Write the description of the abdomen and the sounds. Did the patient had any blood of coffee ground in his nasogastric tube or stools? Did you check for occult blood? Count bowel movements and describe the feces. Diarrhea? Enter the feeding route (PPN, TPN, oral, etc) and devices (eg. central line, gastrostomy, etc). Calculate the amount of calories required and those received. If you have metabolic cart data, albumin and total protein concentrations... enter them here. Nitrogen balance calculations go here too.
Endocrine: Must enter glucose, calcium, phosphorus, Na+, K+, and any other electrolytes that are relevant to your patient's condition. Insulin requirements, if any, over the last 24 hours are written here. Don't forget osmolality if relevant.
Hematologic: Check and note the hemoglobin concentration, hematocrit, platelet counts, WBC counts, PT and PTT. In septic patients you may also add fibrin split products, fibrinogen concentration and blood morphology smears reports.
Immunologic/ID: Check the temperature. Review wounds and infected sites, both by physical examination and by x-rays or other tests; place results here. Check for new infections; write down any suspicious findings. Check the results of cultures, Gram stains; follow the trends of WBC counts and other hematology tests (see above). Check antibiotics, the doses and levels, the clinical response and any apparent side effects (eg. drug rash, fever). It may sound repetitive, but, in patients on nephrotoxic antibiotics, I like to jot down the creatinine levels here to follow the trends.
By the way, it is useful to list any medications under the organ system that they were prescribed for. Always look for side effects, levels (if necessary) and clinical response.
Skin and Musculoskeletal:Describe any decubitus ulcer, rash, burn, wound, ecchymoses, gangrenous changes or unusual discoloration of the skin here (including cyanosis and blue toes). Make sense of your description by adding details about the pattern of distribution of the abnormalities. Add info about the temperature and feel of the skin. Remember to jot down any ointments or other meds the patient is getting. Describe contractures, spasticity, flaccidity of limbs. Also describe any swelling, redness or heat in any joint(s) and the distribution of these abnormalities.
Central Lines: Describe any central lines that the patient has. Add the date when they were placed and, if you are very meticulous, the date you expect to have them changed or discontinued. If they have been changed, state when and by what method.
Some units choose to enter another two types of sections: one section is on rehabilitation (for those patients stable enough to be receiving therapy or being followed by rehab teams from early on). Another section is on education; this section covers any info delivered to the patient or the family about the status of the patient and what to expect next. I like these sections.
The Assessment portion may be done in two ways. I prefer to do a numbered problem list here. The problem may not be a diagnosis, but a clinical observation that needs to be defined further. If so, I state it as such and add possible explanations. Under each problem I state whether the condition is unchanged, improving or deteriorating and how. If this is the first note and you want provide an APACHE score, enter it here. Most ICUs have a separate sheet to calculate the APACHE score though.
Your plan should address each item in the problem list you made in the Assessment portion of the note. Be specific about the steps to take. If a certain situation is predictable, add alternative plans or an algorithm.
Note: Most ICUs use flow sheets. You may follow the trends of a lot of data in them. Or you may choose to write the data with dates in your note, for your own reference. Whatever works.
MISSION ACCOMPLISHED...you may now have breakfast...well...I mean lunch.