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
