ICU Note Templates with Examples

ICU Note Template

This template is used for ICU ward rounds, providing a detailed assessment of the patient's condition. It follows the ABCDEFGHIL format, covering critical aspects like respiratory, cardiovascular, neurological, and other systems that are intensively monitored. Doctors using this AI-powered template can:

• Minimize note-taking time to make space for more important tasks, like focusing on the patient and speaking with family
• Enhance communication with other members of the healthcare team with a standardized multi-organ system assessment
• Ensure that notes are concise and complete for efficient clinical handover

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What is an ICU Note Template?

An ICU note template is a tool used by intensive care specialists and nurses to document the patient’s progress during their stay in the intensive care unit. ICU notes tend to be very comprehensive, often organized by system to make sure that no essential information is missed.

Due to the tightly controlled environment, ICU notes tend to be more detailed than medical notes. This poses a challenge for many clinicians who need time to write notes but must also be prepared for any emergencies. The use of a template removes the mental burden of having to recall specific information. ICU note templates also allow the clinician to return to their notes after responding to an emergency, without losing their train of thought.

In this article, we will share various types of ICU note templates, their importance and key components, essential mnemonics used in the ICU, and tips on how to write good ICU notes.

The Importance of ICU Note Templates

In the ICU, patients are critically ill and monitored 24/7. As a result, ICU notes need to be complete and accurate. The use of an ICU note template can fulfill the following functions:

Structure Notes and Establish a Flow

The use of a template provides a checklist of systems that can easily deteriorate if not monitored properly. With it, examining a patient can be done systematically, rather than going back and forth between systems if one component is forgotten. Additionally, templates provide a clear structure, which gives a 20% increase in the quality of notes compared to nonstructured notes.

Legal and Regulatory Compliance

ICU notes are of significant legal value, as these documents are required for insurance policies and may be examined in malpractice cases. They provide clear objective evidence of the patient’s history and course in the intensive care unit of the hospital, showing a clear picture of what care and management practices were followed.

Assist in Informed Decision-making

Clinical decision-making is informed by the patient’s course in the ICU. One of the defining attributes of efficient decision-making includes proper comprehension of patient data abnormalities. Without proper documentation, there can be misunderstandings about a patient’s condition, which can result in inappropriate management and adverse outcomes.

Provide Educational Value

Many hospitals emphasize proper ICU note-taking for research and educational purposes. With each event and intervention recorded, an analysis of different cases can be done to find patterns that will assist in future cases and help medical students understand similar conditions.

Ensure Patient Safety and Continuity of Care

In the ICU, patients can deteriorate quickly. One anomaly in any system can result in irreversible and even fatal consequences if overlooked. The use of a template helps ensure that each system is accounted for. Without organized notes, treatments can become delayed because information has to be gathered and the rest of the team informed.

Delayed treatment due to unorganized notes is a common problem in healthcare teams. Giving information and orders takes time, especially when notes are unclear. Dr. Tiffany Garner is a medical director and nurse practitioner who used to experience similar problems, causing unnecessary stress and inefficient workflow.

However, this was no longer the case as her use of Heidi, the AI medical scribe for all clinicians, streamlined her internal communications to the point that she didn’t “have to explain notes to the nurses anymore; Heidi summarizes it perfectly." She noticed that her clinicians could see an additional 2 patients per day and significantly improved their chart closures.

Different Formats of ICU Note Templates

There are different approaches to ICU notes. These formats can vary between attending doctors and institutions, so there’s no totally right or wrong method. Here are some common approaches and mnemonics used in ICU notes:

System-based Approach

Starting from the “head to toe”:

• Head/Central Nervous System: This part includes all information about the mental state of the patient such as Glasgow Coma Score (GCS), Richmond Agitation-Sedation Scale (RASS), a full cranial and peripheral exam (where needed), sedative and analgesic medications used, and External Ventricular Drain (EVD) height and output.
• Respiratory: This section covers the ventilator settings, auscultation of lung zones, patient’s saturation, and arterial blood gas results. A description of the state of the endotracheal tube is also placed here.
• Circulatory: This involves checking the patient’s fluid therapy being used, auscultation of the heart, presence of edema, vital signs (such as heart rate, blood pressure, and capillary refill), baseline and serial ECGs, results of echocardiography done, and vasoactive agents being used.
• Gastroenterology: This part details surgical drain monitoring (if any), checking on the nasogastric tube (if placed), weight, bowel output, enteral or parenteral feeding, and diet/calorie intake. A physical exam of the abdomen is also an essential part here.
• Genitourinary: Urine output, electrolytes, fluid intervention, and dialysis should be monitored and noted for this section.
• Blood tests: The results of the blood tests should be documented (ideally in chart form). This also involves transfusion strategies and blood glucose control. Microbiological tests should also be added, if done.
• Imaging tests: This section shows the significant findings of the previous and latest imaging tests done.
• Review of medications: This is generally a list of all the medications currently being used by the patient.

ABCDEFGHIJKLMNOPQ Assessment

This approach to writing an ICU note aims to cover all essential systems, diagnostics, plan, and additional concerns regarding the patient’s condition:

• Airway: Make sure the patient’s airway is patent and protected. Take note of the ventilation settings and the state of the endotracheal tube.
• Breathing: Write down the patient’s respiratory rate, oxygen saturation, and chest auscultation findings.
• Circulation: Check their blood pressure, heart rate, capillary refill, and presence of abnormal heart sounds. Also, list the vasoactive medications being used.
• Disability: Indicate their GCS Score, sedative and analgesic medications, and glucose levels.
• Exposure: Perform a thorough skin examination, emphasizing the presence of lesions (especially bed ulcers), signs of dehydration, and body temperature. This is also where the electrolyte panel can be placed.
• Fluids: Take note of the fluid balance (input and output), urea, creatinine, eGFR levels, and monitor the catheter (if inserted) for this part. Also, check the patency of the venous line.
• Gas/Gastric: List the arterial and venous blood gas results, prescribed nutrition and diet, and liver function tests.
• Hematology: If needed, highlight blood tests done and transfusion strategies.
• Imaging: State all previous and latest imaging findings.
• Jobs: Check if all jobs have been allocated properly within the critical care team.
• ECG: Compare previous ECG results to current results, and list the echocardiography results
• Location: Assess if the patient is in the right place or should be transferred to their room of choice. Ensure the patient is in the proper position and is being turned regularly.
• Monitoring: Specify how often monitoring should be done.
• Next of kin: Inform the family of progress and note any possible apprehensions or agreements regarding the patient’s condition/plan, make sure the next of kin is identified, and that all advanced directives are in order
• Oh, shoot: Stop to review if all findings so far are stable or if they need immediate intervention
• Plan: Outline the next steps for the patient and any interventions that need to be started, continued, modified, or stopped.
• Questions: Remember to ask the patient or their companions if they have any concerns about the medical plan.

FAST HUGS IN BED Please

This is a modified version of the classic FASTHUGS mnemonic commonly used in ICUs around the world. However, please note that some resources use different meanings for parts of the mnemonic. Listed below are some of the common meanings:

• Fluid therapy and feeding
• Analgesia and Antiemetics
• Sedation and Spontaneous breathing trial
• Thromboprophylaxis, Tetanus prophylaxis
• Head position
• Ulcer prophylaxis
• Glycemic control
• Skin or Suctioning (eye care)
• Indwelling catheter or Interdisciplinary care
• Nasogastric tube or NEWS2 score
• Bowel care
• Environment
• De-escalation or Discontinue care
• Psychosocial support

How to Write Good ICU Notes with Examples

Writing ICU notes can be done by anyone with the right template. However, that doesn’t automatically make the documentation high-quality. Here are a few tips to ensure that your notes are as comprehensive and accurate as possible:

Study the patient’s course before rounds

It’s difficult to understand the condition of the patient without knowing what led to their current state. With the use of electronic records, and even AI scribes that can automatically summarize patient histories, a lot of time can be shaved off familiarizing yourself with a patient’s situation.

Use quantifiable information

Be specific about laboratory work and medical plans. Instead of using statements like “Normal blood pressure and heart rate,” or “Platelet count and hemoglobin is within normal range,” use numbers and quantify the amount. State that “Blood pressure is 180/30 and heart rate is at 88 bpm”. It seems tedious, but it’s not enough to say that results are normal because management is influenced by specific thresholds for labs and vital signs.

Maintain objectivity

Make sure that only objective information is used and no assumptions are made about the patient. Rather than stating that the “patient seems agitated or nervous,” it’s preferable to use more objective terminology, such as, “The patient has expressed their concern regarding this plan.”

Minimize the use of non-standard abbreviations

There are standard abbreviations for units, medication frequencies, and machine names, among others. However, there are non-standard abbreviations that can be mistaken for another meaning. For example, the abbreviation “SSRI” for sliding scale regular insulin can be mistaken for selective serotonin reuptake inhibitor. Avoid abbreviating drug names for the same reason. For example, “HCT” for hydrocortisone can be mistaken for hydrochlorothiazide.

Document in real-time

In the high-pressure environment of the ICU, clinicians tend to alternate between interacting with the patient and pausing to jot down notes. While unavoidable at most times, this practice can negatively impact rapport, engagement, and the strength of the doctor-patient relationship.

Recording notes in real-time was a real struggle faced by Dr. Shelagh Fraser wherein patient encounters would even be “[...] cut short a patient encounter, so they would have enough time to write their note before the next patient.”

But after using Heidi as her AI scribe, the burden of jotting notes during patient encounters has been largely reduced, stating that, “It allows me just to talk to them. I’m not trying to type the whole time. We are just listening and communicating and really being present.” 

ICU Notes Template Example

Following a specific format filled with extensive details can be mentally taxing to remember. Using Heidi Health’s AI medical scribe provides a way to easily take notes while doing your examinations, easing the worry of having to memorize all the important information.

Easily Write Detailed and Accurate ICU Notes with Heidi

Heidi can easily be accessed on your devices, like your laptop, tablet, or smartphone, as you bring them on patient rounds. Once you open the app, you can easily start taking notes as you go when you press ‘Start transcribing’:

• Transcribe: As you’re examining the patient, Heidi sits quietly in the background and transcribes everything that takes place. Even discussions with the family or medical team can be heard and summarized.
• Transform: After your patient interactions, Heidi organizes these conversations according to the format of your preferred template, covering the most essential aspects of the patient’s condition, management, or treatment plan.
• Customize: If the template does not exactly match what you’re looking for, you’re free to edit it and add custom fields that are appropriate for your case and note-taking style.

Heidi is a safe space. There’s no need to worry about data security, as Heidi ensures global compliance with patient safety regulations (HIPAA, GDPR, PIPEDA, APP) and has invested in top-notch certifications with security frameworks like ISO27001 and SOC2.

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Related ICU Note Templates

Systems-based ICU Note Template

This template follows a systems-based approach to ICU note-writing. It lists down the existing issues of the patient and progress since the last admission. Afterwards, this AI-powered ICU note template organizes information from airway to renal findings and mobility before stating the plan.

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Medical ICU Progress Note Template

This template is focused on patients receiving acute medical treatment, focusing on each condition, which has its own assessment and plan. When used with Heidi, clinicians can address each condition one by one and discuss it with the patient, allowing for better understanding, while also transcribing it for later review.

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Surgical ICU Daily Notes Template

This template can be used by clinicians who have patients who have undergone surgery and are then sent to the ICU. It documents their progress, management, and follow-up care post-surgery within the hospital setting.

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FAQs About ICU Notes

What is an ICU short note?

An ICU short note, as the name implies, is a shorter version of an ICU note. It usually follows the SOAP note framework, but it leaves out information such as detailed patient history, comprehensive discussions with the patient and their family, routine and normal labs and findings, and an extensive review of systems.

What is the main difference between an ICU admission note template and an ICU transfer note template?

The ICU transfer note is written when a patient is being transferred from the wards, operating room, or emergency room to the ICU. It details the patient’s condition, progress before transfer, operations done, medications being taken, and the plan of care. On the other hand, the ICU admission note is usually written by the team receiving the patient when they do a re-history and re-examination once the patient has settled in.

How can I create my own ICU note templates?

Heidi has an array of ICU note templates that are free to use. You can easily make your own template by creating a free account. Then, go to your personal template library and click “Create template”. Choose either based on the existing note or start with a blank template. For the former, copy and paste a sample ICU note, then add or remove parts of the template until it matches the one you have in mind. For the latter, you can make your own template structure based on the instructions on the right side of the window. For more detailed guidance, visit this Heidi Guide.