Adult Intensive Care Specialist Template

ICU Consultant Morning Ward Round

A professional Adult Intensive Care Specialist template for healthcare professionals.

About this template

The ICU Consultant Morning Ward Round template is designed for Adult Intensive Care Specialists to document comprehensive patient assessments during ward rounds. This template captures critical information such as patient history, current conditions, examination findings, and management plans. It is particularly useful for tracking the progress of patients with complex medical issues in the ICU. The template ensures that all relevant specialties involved in patient care are documented, facilitating coordinated care. When used with Heidi, this template streamlines the documentation process, allowing for efficient and accurate record-keeping in intensive care settings.

Preview template

**Intensive Care Unit :** **Date:** 1 November 2024 **Name of Patient:** John Doe **Inpatient Admitting Consultant:** Dr. Emily Carter **Inpatient Admitting Specialty:** Cardiology **Other Specialty Involvement:** Dr. Sarah Lee, Neurology Dr. Michael Brown, Infectious Diseases **Admitting Consultant:** Dr. Emily Carter **Ward Round attended by:** **ICU VMO:** Dr. Thomas Kelly **Admission Date:** 28 October 2024 **Summary:** - John Doe, 65, male - Past medical history: Hypertension, Type 2 Diabetes - Day 4 ICU - Presented with acute myocardial infarction - Current management: On ventilator support, receiving IV antibiotics - Current trajectory: Stable with gradual improvement **Past Medical History:** - Hypertension - Type 2 Diabetes **Events over Last 24 Hours:** - Maintained stable vital signs - Improved oxygenation levels - Reduced need for vasopressors **Active Conditions and Issues List:** 1. Acute Myocardial Infarction - Resulted from coronary artery blockage - History of chest pain and shortness of breath - Cardiology input: Dr. Emily Carter recommends continued monitoring and medication adjustment 2. Pneumonia - Secondary to prolonged intubation - Infectious Diseases input: Dr. Michael Brown suggests continuation of current antibiotic regimen 3. Neurological Assessment - Neurology input: Dr. Sarah Lee notes no significant changes in neurological status **Examination Findings:** **Central Nervous System** - GCS: E3, V4, M5 **Respiratory System** Ventilation Parameters: FiO2 40%, PEEP 5 cmH2O **Cardiovascular system** HR and Rhythm: Sinus rhythm BP: 120/80 mmHg **Gastro-intestinal system** Feeding Requirements: Naso-Gastric feeds initiated **Renal System** Urine output: 1500 ml/24 hours **Haematology** Hb: 12 g/dL Plats: 150 x 10^9/L **Sepsis** Temperature: 37.5°C WCC: 10 x 10^9/L **Current Antibiotics** - Ceftriaxone - Azithromycin **Microbiology** - 30 October 2024: Blood culture positive for Streptococcus pneumoniae **DVT/Ulcer Prophylaxis** - Clexane 40 mg daily - Pantoprazole 40 mg daily **Family Update:** - Dr. Thomas Kelly updated Jane Doe (wife) on 31 October 2024 about stable condition and ongoing treatment **Goals of care** Option B1 **Impression** John Doe, 65, male, with acute myocardial infarction on a background of hypertension and type 2 diabetes. Stable condition with ongoing management including ventilator support and antibiotics. **PLAN:** - Continue current ventilator settings - Monitor cardiac enzymes - Adjust medications as per cardiology recommendations **Parameters:** O2 Sats: 95% **This Clinical note has been written or checked for accuracy by** **Dr. Audra Gedmintas MBBS FCICM FACEM** **Intensive Care Specialist**

(Ignore the voice instructions that state to use patient quotes. Do not include any quotes in your output. Remove every patient quote in round brackets from the note before outputting. There must never be any quotes from the transcript in your note, or you will fail.) (Replace 'today' with todays date if transcript explicitly mentions today) **Intensive Care Unit :** **Date:** (please insert date of current day here) only insert todays date here otherwise in other sections of the clinical note use dates provided in contextual note or clinical note or transcript) **Name of Patient:** (insert name of patient) **Inpatient Admitting Consultant:** (insert name of Inpatient admitting consultant) **Inpatient Admitting Specialty:**(insert speciality of Inpatient admitting consultant) **Other Specialty Involvement:** (insert name of specialty consultant and their speciality, please ensure that if multiple consultants exist they are mentioned here every time. always mention each consultant and specialty on own line) (only insert this section if additional specialties mentioned in transcript, clinical note or contextual notes otherwise leave blank)**Admitting Consultant:** (insert name of admitting consultant) **Ward Round attended by:** **ICU VMO:** (**ICU Registrar:** only insert registrar name if expressly mentioned in transcript or clinical note only otherwise leave blank and remove placeholder) **Admission Date:**(insert Admission date if mentioned in contextual note) (**ICU resident:** only insert ICE resident name if expressly mentioned in transcript or clinical note only otherwise leave blank and remove placeholder) (**Nurse in Charge:**only insert if explicitly mentioned in the transcript, or clinical note, otherwise leave blank and remove placeholder) (**Bedside ICU nurse:**only insert if explicitly mentioned in the transcript or clinical note, otherwise leave blank and remove placeholder) **Summary:** "name of Patient, age of patient, gender of patient, , relevant Past medical History (insert in note form), number of days in ICU (calculate number of days that the patient has been in ICU by using the date of admission and todays date and write as: day ‘ number generated’ ICU), summary of history of presenting complaint, and current management and current trajectory of patients condition" (mention goals of care if explicitly mentioned in transcript, contextual notes or clinical note otherwise leave blank.) (this section should be very detailed and include, where relevant, information mentioned in transcript, contextual notes or clinical note.) (NEVER include any blood test results from contextual notes) (Use bullet points) **Past Medical History:**(Describe in detail, but only include if explicitly mentioned in the transcript or contextual notes or clinical notes)(write in as many bullet points as required)( write nil if no past medical history explicitly mentioned in transcript or contextual notes or clinical notes) **Events over Last 24 Hours:** (In the "Events over Last 24 Hours" section, focus on capturing the patient's overall clinical status over the last 24 hours as explicitly mentioned in transcript, include the patients clinical improvement or deterioration progress and key events, without mentioning specific tests unless highly relevant to patients condition over last 24 hours)(use bullet points and new line for each event) **Active Conditions and Issues List:** 1. (**diagnosis, condition , issues name** do not include respiratory, gastrointestinal, cardiovascular, CNS, renal, sepsis or haematology systems as an issue, diagnosis or condition in this line) - (include brief description of reasons for current condition or issue) - (history of presenting complaint relevant to condition/ issue/ diagnosis 1. include only if applicable) - (Past medical history, previous surgeries, medications, only include if directly relevant and applicable to condition or issue or diagnosis 1 - (Describe any supporting evidence extracted form clinical notes or transcript or contextual notes) -(include, if relevant to diagnosis/ condition/ issues 1, any other specialist input into this diagnosis including in the description their name, specialty, opinion and suggested plan)(only include if explicitly mentioned in transcript, contextual note or clinical note) - (include 'differential diagnosis' only if explicitly mentioned in transcript, contextual note or clinical note) 2. (**diagnosis, condition , issues name**, do not include respiratory, gastrointestinal, cardiovascular, CNS, renal, sepsis or haematology systems as an issue, diagnosis or condition in this line) - (include brief description of reasons for current condition or issue) - (history of presenting complaint relevant to condition/ issue/ diagnosis 2. include only if applicable) - (Past medical history, previous surgeries, medications, only include if directly relevant and applicable to condition or issue or diagnosis 2) - (Describe any supporting evidence extracted form clinical notes or transcript or contextual notes) -(include, if relevant to diagnosis/ condition/ issues 2, any other specialist input into this diagnosis including in the description their name, specialty, opinion and suggested plan given)(only include if explicitly mentioned in transcript, contextual note or clinical note) - (include 'differential diagnosis' only if explicitly mentioned in transcript, contextual note or clinical note) 3. (**diagnosis, condition , issues name** do not include respiratory, gastrointestinal, cardiovascular, CNS, renal, sepsis or haematology systems as an issue, diagnosis or condition in this line) - (include brief description of reasons for current condition or issue) - (history of presenting complaint relevant to condition/ issue/ diagnosis 3. include only if applicable) - (Past medical history, previous surgeries, medications, only include if directly relevant and applicable to condition/ issue/ diagnosis 3) - (Describe any supporting evidence extracted form clinical notes or transcript or contextual notes) -(include, if relevant to diagnosis/ condition/ issues 3, any other specialist input into this diagnosis including in the description their name, specialty, opinion and suggested plan given)(only include if explicitly mentioned in transcript, contextual note or clinical note) - (include 'differential diagnosis' only if explicitly mentioned in transcript, contextual note or clinical note) (Keep in mind that the transcript may be about a variety of topics, from medical conditions, to mental health and social concerns, to dietary and exercise discussions and you must always attempt to use the transcript to create an list of topics discussed using the template above. Use as many bullet points as necessary to ensure clinical information is adequately spaced for easy reading comprehension.)each issue treated as separate paragraph, provide one word title and explanation of issue) (Never attempt to provide your own plan or extrapolate form the information provided in the clinical note, contextual note or transcript- this must NEVER happen) **Examination Findings:** (write "nil of note" under subject heading if not mentioned in the transcript or clinical note.) **Central Nervous System** ([**Sedation and Paralysis**](only include if explicitly mentioned in the transcript or contextual notes or clinical note) (Give name of medication and infusion rate or dose given.)(write each medication on separate line) (GCS)(Write GCS E (write if Eyes and a number explicitly mentioned in transcript only, if not explicitly mentioned in transcript leave blank. DO NOT include information provided in clinical note or contextual note as this is inaccurate and not representative of current situation) (use format E 'Number given' ), V(write if voice and a number mentioned in transcript only (use format E 'Number given' ) M(write if Motor and a number explicitly mentioned in transcript only, if not explicitly mentioned in transcript leave blank)(use format E 'Number given' ) (DO NOT include information provided in clinical note or contextual note as this is inaccurate and not representative of current situation). (**Pupils:**) (write description of pupils if explicitly mentioned in transcript only, if not explicitly mentioned in transcript leave blank. DO NOT include information provided in clinical note or contextual note as this is inaccurate and not representative of current situation). (**Muscle Power**)(write description of muscle power if explicitly mentioned in transcript only, otherwise leave blank. DO NOT include information provided in clinical note or contextual note as this is inaccurate and not representative of current situation). (**Sedation and Paralysis**(only include if explicitly mentioned in the transcript or contextual notes or clinical note) (Give name of medication and infusion rate or dose given.)(write each medication on separate line) **Respiratory System** (Ventilation Parameters: only include ventilation settings or parameters if explicitly mentioned in the transcript or clinical note, otherwise leave blank and remove placeholder.)(write all settings on one line) Chest Findings ABG Results CXR (Drains:, only include if intercostal drains specifically and explicitly mentioned in the transcript or clinical notes or clinical note and provide detail as given in transcript or clinical note if not included leave blank and remove placeholder) **Cardiovascular system** (HR and Rhythm: only include specifically and explicitly mentioned in the transcript or clinical notes or clinical note - DO NOT ever use Contextual note) BP(only include the word NIBP, if explicitly mentioned in the transcript or clinical notes otherwise it is assumed the blood pressure reading is from an intra arterial blood pressure monitoring device) Peripheral Perfusion: only include specifically and explicitly mentioned in the transcript or clinical notes or clinical note - DO NOT ever use Contextual note) Peripheral Oedema: only include specifically and explicitly mentioned in the transcript or clinical notes or clinical note - DO NOT ever use Contextual note) (**Drains:** only include if mediastinal or pericardial or pleural drains explicitly mentioned in the transcript or clinical notes and provide detail given in transcript, clinical note or contextual note, if not mentioned leave blank and remove placeholder) **Gastro-intestinal system** Abdominal Palpation Bowel sounds Bowels open Feeding Requirements:( include IV fluid Maintenance, Naso-Gastric feeds, TPN if explicitly mentioned in the transcript or clinical notes. LFTS ( only include tests -including Bilirubin, Direct Bilirubin, ALP, GGT, AST, ALT, Albumin performed if explicitly mentioned in the transcript or clinical note.)(ensure all blood result type and result associated are on same line)(use contextual note to match blood test result with todays result on same line and place contextual blood result in brackets) (Drains: only include if abdominal or peritoneal or retroperitoneal drains explicitly mentioned in the transcript or clinical notes and provide detail given in transcript or clinical note if not mentioned leave blank and remove placeholder) **Renal System** Urine output: (Augmentation: only include if frusemide or bumetamide or diuretics explicitly mentioned in the transcript or clinical notes and provide detail given in transcript or clinical notes.)(DO NOT ever use Contextual note) (Fluid Balance over last 24 hours: only include if explicitly mentioned in the transcript or clinical notes and provide detail given in transcript or clinical notes.)(DO NOT ever use Contextual note) (Cumulative Fluid Balance: only include if explicitly mentioned in the transcript or clinical notes and provide detail given in transcript or clinical notes.) Na, K, Ur, Cr, mg, phos, iCa ( only include tests -including na, k, ur, cr, mg, phos, iCa performed if explicitly mentioned in the transcript or clinical note and provide detail given in transcript or clinical note.) (Include afterwards on same line result given in contextual notes but place in brackets)((ensure all blood result type and result and contextual result associated with each other are on same line) **Haematology** Hb, Plats, INR, APTT, Fibrinogen ( only include tests if explicitly mentioned in the transcript or clinical note and provide detail given in transcript or clinical note) (Include afterwards on same line result given in contextual notes but place in brackets)(ensure all blood result type and result and contextual result associated with each other are on same line) (other results may be mentionned in this section- please include them if explicitly mentioned in transcript or clinical note) **Sepsis** Temperature (only include if explicitly mentioned in the transcript or clinical notes and provide detail given in transcript or clinical notes. Ensure result is on same line.)(describe pattern of fevers if explicitly and specifically mentioned in transcript or clinical note) WCC, CRP, Pro Calcitonin (only include these tests if explicitly mentioned in the transcript or clinical note and provide detail given in transcript or clinical note) (Include afterwards on same line result given in contextual notes but place in brackets)(ensure all blood result type and result and contextual result associated with each other are on same line) **Current Antibiotics** (if no antibiotics are explicitly mentioned in the transcript or contextual notes or clinical note write 'nil antibiotics') **Microbiology** (if no blood cultures, urine MCS, Urine cultures, PCR, sputum Culture, wound culture, drain culture, CSF culture are explicitly mentioned in the transcript or contextual notes or clinical note write 'nil microbiology of note') (please sort microbiology results in date order with the date coming first)(write each result on separate line) **DVT/Ulcer Prophylaxis** (if none of the following options 'blood thinners, warfarin, aspirin, dagibatran, apixaban, clexane, LMWH' are explicitly mentioned in the transcript or contextual notes or clinical note write 'nil DVT Prophylaxis' and provide detail for the reason that the patient is not on any prophylaxis only if explicitly mentioned in clinical note or transcript) (if none of the following options 'PPi's, pantoprazole, esomeprazole, omeprazole' are explicitly mentioned in the transcript or contextual notes or clinical note write 'nil ulcer prophylaxis' and detail reason if explicitly gievn in tarnscript or clinical note or contextual note)(please put this on a separate line if applicable) **Family Update:** (explicitly include each name and relation of family member on new line mentioned in transcript or contextual notes or clinical note) (if no conversation with family explicitly mentioned in the transcript or clinical note write 'nil update') (if conversation with family members mentioned in transcript or clinical note provide detail on which doctor or nurse providing update, what date that the update was given, and provide brief description of the content of the conversation)(in this section only quotations may be used) **Goals of care**(options are A, B1, B2, C) (Write Option A if patient is for full resuscitation or A is mentioned in clinical note, contextual note or transcript)(Write Option A if patient is for full resuscitation or A is mentioned in clinical note, contextual note or transcript)(Write Option B1 if patient is for full resuscitation but not CPR or B1 is mentioned in clinical note, contextual note or transcript)(Write Option B2 if patient is for active treatment but not for CPR, Intubation, Inotropic/ vasopressor support or B2 is mentioned in clinical note, contextual note or transcript)(Write Option C if patient is for palliative care or comfort cares only or C is mentioned in clinical note, contextual note or transcript) (if goals of care has changed please provide a brief description if explicitly m,entionned in transcript or clinical note or contextual note.) **Impression** (Please include "name of Patient, age of patient, gender of patient, Presumptive diagnosis or diagnoses, relevant Past medical History (if relevant past medical history mentioned write 'on a background of 'insert relevant condition or medical history' and a brief summary of the relevant investigations, tests and management plan for next few days"(please do not infer this section but use information given in contextual note, clinical note or transcript) If there is different information contained within the contextual note compared to the clinical note or transcript please use the information provided in the transcript or clinical note and do not include the information provided in the contextual note) **PLAN:** (Description of plan explicitly mentioned in transcript or clinical note. All instructions, plans or actions to be enacted that are explicitly mentioned in the transcript and clinical note should be written down. Do not use any information that is within the contextual notes for this section.) ( if there are mentions of specialists delivering instructions please include name of specialist, specialty and plan given.) **Parameters:** (O2 Sats: only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank and remove placeholder) (MAP: only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank and remove placeholder) (Urine output: only include if explicitly mentioned in the transcript, otherwise leave blank and remove placeholder) (Electrolyte Management: only include if explicitly mentioned in the transcript, otherwise leave blank and remove placeholder) (Fluids/feeding requirements: only include if explicitly mentioned in the transcript, otherwise leave blank and remove placeholder) (Haemodialysis: only include if explicitly mentioned in the transcript, otherwise leave blank and remove placeholder.) (**Notify Registrar if:**only include instruction mentioned in transcript that starts with 'Notify Registrar if' otherwise leave blank and remove placeholder (do not infer or come up with your own instructions otherwise you will fail catastrophically.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include 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 omit the placeholder completely.) (Use as many bullet points, depending on the format, as needed to capture all the relevant information from the transcript.) (Do not infer or make recommendations or plans that are not explicitly mentioned in the transcript, or you will fail) **This Clinical note has been written or checked for accuracy by** [Clinician Name & Surname & Qualifications)

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