Scribe BC - ICU progress note

**Morning rounds, ICU day**: [insert current ICU day since admission and state in format Day (insert number)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Counts days from date of admission to icu which is day 1.) **Date of ICU Admission**: [insert icu admission calendar date YYYY/MM/DD] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **ICU doctors**: [list of ICU attending physicians and residents] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Active Problem List**: [include active issues, working diagnosis, differential diagnosis, organ failures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Use bullet points.) **Pre-admission diagnoses/Past Medical History**: [include past medical history, chronic medical problems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Use bullet points.) **Surgical history & procedures**: [list of surgical procedures and dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Medications**: [List medications, include insulin doses here as well as all infusions given] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Enoxaparin should be used instead of enox or oxaparin.) **Management Plan**: [include medications with disease being treated, indication for each medication, include antibiotics, tests pending, tests ordered, include ventilator and respiratory therapies, include vasoactive medications. Put quotes here word for word without modification. Include antibiotics and blood pressure medications such as vasopressors such as levophed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Use bullet points.) **Consultants**: [list consultants and specialists names and recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **CNS exam**: [include RASS, CPOT score, GCS; medications including sedatives, units to be used for preceded infusion are mcg/kg/hr, propofol dosing units are mcg/kg/min iv, versed dosimg units are mg/hr iv, fentanyl dosing units are mg/hr iv, dilaudid, morphine, include mobility & activity, pain and CPOT score, sleep][prop means propafol, fent means fentanyl][hydromorph means hydromorphone dosed in mg/hr iv]["without pressures" means "without pressors"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Cardiovascular exam**: [include levophed or norepinephrine (mg/min iv), intravenous blood pressure medicines, dobutamine, vasopressin (units/min iv), epinephrine (mcg/min iv)][levo means levophed][IJ means internal jugular central line][include JVP] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Respiratory exam**: [Change High flow oxygen to proper term: High Flow Nasal Cannula or abbreviate as HFNC] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Gastrointestinal exam**: [include NG or OG tubes, FMS (fecal management tube). rectal tubes, JP drains, abdominal dressings or wounds, paracentesis drains, TPN (total parenteral nutrition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Genitourinary exam**: [include presence and severity of edema, and include fluid balance, include foley and suprapubic cathetres, nephrostomy drains] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Endocrine**: [exclude diagnoses, but include results of blood sugar, glucose, insulin doses, systemic steroid medications, thyroid][insulin pump, insulin doses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Skin**: [CWMS and skin findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Lines & tubes**: [list all central lines, peripheral lines, tubes, and access points] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Infection & microbiology**: [include culture results, fluid analysis results, antibiotics and exclude diagnoses, include temperature and T max, interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Labs**: [laboratory results organized by category] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Put cbc on one line; electrolytes, bun, creatinine, egfr on another line, and all other labs on another line.) **Imaging**: [include xray, CT, MRI, ultrasound results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **DVT prophylaxis/GI prophylaxis**: [prophylaxis medications and devices] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Substitute enox with enoxaparin. Put SCD (which means sequential compression device) here.) **Ventilatory support, Vasoactive medications**: [detailed ventilator settings and vasoactive medication dosing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Social History**: [family members, spouse, common law, partner, friend] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. List current or previous occupation, profession, job, work, employment. Add any conversations I had with family.) **Code status**: [include code MOST, TSDM (temporary substitute decision maker)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Include code status where the only options are cprc2, dnacpr2, dnacprc1, dnacprm3, dnacprm1.) **Critical Care**: [critical care specific assessments and plans] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) "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." (Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)