Critical Care Medicine Specialist-Vorlage
Scribe BC - ICU progress note
Eine professionelle Critical Care Medicine Specialist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
This ICU progress note template is designed for critical care medicine specialists to efficiently document patient care in the intensive care unit. It covers essential elements like active problems, medications, management plans, and various system exams. This template helps streamline documentation, ensuring all critical information is captured, which is especially useful when using an AI scribe like Heidi. Using this template with Heidi can save time and improve the accuracy of your clinical notes, allowing you to focus more on patient care.
Vorlagenvorschau
**Morning rounds, ICU day**: Day 3
**Date of ICU Admission**: 2024/10/30
**ICU doctors**: Dr. Emily Carter, Dr. Ben Miller, Resident: Dr. Sarah Jones
**Active Problem List**:
* Acute Respiratory Distress Syndrome (ARDS)
* Septic Shock
* Acute Kidney Injury (AKI)
* Ventilator-Associated Pneumonia (VAP)
**Pre-admission diagnoses/Past Medical History**:
* Hypertension
* Type 2 Diabetes Mellitus
* Hyperlipidemia
**Surgical history & procedures**:
* Appendectomy, 2010
**Medications**:
* Piperacillin/Tazobactam 3.375g IV q6h
* Vancomycin 1g IV q12h
* Fentanyl 50 mcg/hr IV
* Midazolam 2 mg/hr IV
* Insulin Glargine 10 units subcutaneously daily
* Insulin Lispro sliding scale
* Enoxaparin 40mg subcutaneously daily
* Norepinephrine 4 mcg/min IV
**Management Plan**:
* Continue antibiotics for VAP: "Piperacillin/Tazobactam 3.375g IV q6h and Vancomycin 1g IV q12h"
* Continue Fentanyl and Midazolam for sedation.
* Continue insulin sliding scale for blood glucose control.
* Continue Enoxaparin for DVT prophylaxis.
* Continue Norepinephrine for blood pressure support: "Norepinephrine 4 mcg/min IV"
* Wean ventilator settings as tolerated.
* Monitor urine output and renal function.
* Daily labs and CXR.
**Consultants**:
* Pulmonology: Continue current respiratory support, consider bronchoscopy if no improvement.
* Nephrology: Continue current management of AKI.
**CNS exam**:
RASS -2, CPOT 1, GCS 10. Sedated on Fentanyl 50 mcg/hr IV and Midazolam 2 mg/hr IV. Mobility limited due to sedation and weakness. Pain controlled. Sleep disrupted.
**Cardiovascular exam**:
Norepinephrine 4 mcg/min IV. BP stable. No JVP.
**Respiratory exam**:
Patient intubated and mechanically ventilated. HFNC. ABGs stable.
**Gastrointestinal exam**:
NG tube in place, draining clear secretions. Abdomen soft, non-tender.
**Genitourinary exam**:
Foley catheter in place, urine output adequate. No edema.
**Endocrine**:
Blood glucose 140 mg/dL. Insulin Lispro sliding scale. Insulin Glargine 10 units subcutaneously daily.
**Skin**:
CWMS intact. No skin breakdown noted.
**Lines & tubes**:
Central venous catheter in right internal jugular vein. Foley catheter. NG tube.
**Infection & microbiology**:
Blood cultures pending. Sputum culture positive for Pseudomonas aeruginosa. Temperature 38.5°C. Started on Piperacillin/Tazobactam and Vancomycin.
**Labs**:
CBC: WBC 18.2, Hgb 10.1, Plt 250
Electrolytes: Na 140, K 4.0, Cl 100, HCO3 22, BUN 30, Creatinine 1.8, eGFR 40
Other labs pending.
**Imaging**:
CXR: Shows bilateral infiltrates consistent with ARDS.
**DVT prophylaxis/GI prophylaxis**:
Enoxaparin 40mg subcutaneously daily. SCDs in place.
**Ventilatory support, Vasoactive medications**:
Ventilator settings: PEEP 10, FiO2 60%, RR 20, Vt 400. Norepinephrine 4 mcg/min IV.
**Social History**:
Patient's wife present at bedside. Patient was a construction worker.
**Code status**:
Full code.
**Critical Care**:
Monitoring for signs of sepsis and ARDS progression. Daily assessment of sedation and ventilator settings.
"The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks."
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