ICU Note

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ICU Note

Plan

Plan for each system, medications, consultation

Condition

Prophylaxis

Confirm if it is active and justify if not

Family/Next of kin

Update Family members, show compassion, and respect wishes

Code Status

Do cument code status

Disposition

Decide level of care according to the clinical condition

Core Measures

Example

Assessment

List Active Diagnoses

Consultations

Update recommendations

Medications

Check start date

Check duration

Imagings

Include: CXR, CT, Echo, U/S, others

Micro and Patho

Updated

Previous

Labs

Pertinent New Labs

Trending Values

Systems

Objective Data

I/O

Drains and Lines

Supportive Devices

Mechanical Ventilation

Invasive Monitoring

Daily Physical Examination

Subjective Data

History & Daily C/O

Demographic Info

Pay attention to the weight