Scribe BC - ICU Ward Round Note (ABCDEFGHIL Assessment)
Synopsis and Progress
- The patient, [insert age] year old male, was admitted to the ICU on 28 October 2024 due to severe sepsis secondary to community-acquired pneumonia. He has a history of hypertension and type 2 diabetes. He initially presented with fever, cough, and shortness of breath. He required intubation and mechanical ventilation upon arrival.
A - Airway is secured with an endotracheal tube, size 8.0, at 22cm at the lip. The patient is tolerating the tube well. No signs of obstruction. Suctioned clear secretions.
B - Respiratory status: Ventilator settings: Assist Control, FiO2 40%, PEEP 5 cm H2O, RR 16, Vt 450ml. Oxygen saturation is 96%. Bilateral equal air entry. Chest X-ray shows improving consolidation in the right lower lobe. Arterial blood gas (ABG) shows pH 7.38, PaCO2 42 mmHg, PaO2 88 mmHg, HCO3 24 mEq/L.
C - Cardiovascular status: Blood pressure 120/70 mmHg, heart rate 88 bpm, regular rhythm. Patient is on norepinephrine 0.1 mcg/kg/min for blood pressure support. No new arrhythmias. Cardiac output is stable. No signs of ischemia.
D - Neurological status: Glasgow Coma Scale (GCS) score is 15. Patient is awake, alert, and oriented. Sedation weaned off. Pupils equal and reactive to light. No focal neurological deficits.
E - Skin condition: Skin is intact. No signs of pressure ulcers. IV site on the left arm is clean and dry. Electrolytes: Sodium 138 mEq/L, Potassium 4.0 mEq/L, Chloride 102 mEq/L, Bicarbonate 24 mEq/L.
F - Fluid balance: Input: 2000ml IV fluids, 500ml enteral feeds. Output: 1000ml urine, 200ml from drains. Net positive fluid balance. Urea 35 mg/dL, Creatinine 1.2 mg/dL, GFR 65 mL/min/1.73m².
G - Gastrointestinal status: Bowel sounds present. Tolerating enteral feeds at 50ml/hr. No abdominal distension. Liver function tests are within normal limits.
H - Hematological status: Hemoglobin 10.5 g/dL. Platelets 180 x 10^9/L. White blood cell count 12 x 10^9/L. No active bleeding. No transfusions required.
I - Signs of infection: Temperature 37.8°C. Blood cultures pending. Sputum culture pending. Started on broad-spectrum antibiotics (meropenem and vancomycin).
L - Lines, tubes, drains: Central venous catheter in right internal jugular vein. Arterial line in the left radial artery. Foley catheter in place. Chest tube on the right side draining minimal serous fluid.
FASTHUGS:
- Feeding: Enteral feeds at 50ml/hr via nasogastric tube.
- Analgesia: Patient is receiving paracetamol 1g IV every 6 hours.
- Sedation: Sedation weaned off.
- Thromboprophylaxis: Enoxaparin 40mg subcutaneously daily.
- Head-up: Head of bed elevated to 30 degrees.
- Ulcer prophylaxis: Pantoprazole 40mg IV daily.
- Glycemic control: Blood glucose monitoring every 4 hours. Insulin sliding scale as needed.
PLAN:
- Continue antibiotics and monitor cultures.
- Wean ventilator settings as tolerated.
- Monitor fluid balance and electrolytes.
- Continue enteral feeds and advance as tolerated.
- Monitor neurological status.
- Daily chest X-ray.
"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."
Scribe BC - ICU Ward Round Note (ABCDEFGHIL Assessment)
Synopsis and Progress
- [provide a brief summary of the patient's current condition, including diagnosis, relevant history, and reason for ICU admission] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
A - [describe airway status, any interventions, and current management] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
B - [describe respiratory status, ventilator settings, oxygen requirements, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
C - [describe cardiovascular status, blood pressure, heart rate, medications, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
D - [describe neurological status, Glasgow Coma Scale (GCS) score, sedation, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
E - [describe skin condition, wounds, and any interventions] - [include lab results of electrolytes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned.)
F - [describe fluid balance, input/output, IV fluids, lab results of urea, creatinine, GFR and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
G - [describe gastrointestinal status, nutrition, bowel movements, liver function tests, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
H - [describe hematological status, lab results, transfusions, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
I - [describe signs of infection, temperature, cultures, antibiotics, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
L - [describe lines, tubes, drains, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
FASTHUGS:
- Feeding: [describe nutritional support, enteral/parenteral feeding, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
- Analgesia: [describe pain management, medications, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
- Sedation: [describe sedation management, medications, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
- Thromboprophylaxis: [describe measures for preventing thrombosis, medications, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
- Head-up: [describe head elevation, positioning, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
- Ulcer prophylaxis: [describe measures for preventing ulcers, medications, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
- Glycemic control: [describe blood sugar management, medications, and any interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
PLAN: [Describe management plan in non-numbered dot points] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder 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.)