ICU Daily Progress Note

**Date:** [Current date] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Name:** [Patient name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) ICU Day [Day number] Assessment **Diagnoses:** [List of active diagnoses relevant to the current ICU admission] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) **Course over the Last 24 Hours and Subjective:** [Patient's subjective complaints, comfort level, pain assessment, and any concerns expressed by the patient or family] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) [Sequence of events and clinical course over the last 24 hours] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Objective:** **Vital Signs:** [Temperature, heart rate, blood pressure, respiratory rate, oxygen saturation, and any other monitored parameters with specific values] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Physical Examination:** [General appearance and level of consciousness] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Cardiovascular examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Pulmonary examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Abdominal examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Neurological examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Extremities and skin examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Ventilator Settings and Respiratory Status:** [Current ventilator mode and settings including fraction of inspired oxygen, positive end-expiratory pressure, tidal volume, and respiratory rate] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Arterial blood gas results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Respiratory mechanics and compliance findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Haemodynamic Support:** [Current vasopressor agents including doses and titration details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Inotropic support details including agents and doses] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Haemodynamic monitoring parameters and values] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Devices and Lines:** [Central venous access, arterial lines, and monitoring devices in situ] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Nasogastric tube position, output, and function] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Urinary catheter status and output] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Other devices or monitoring equipment in use] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Laboratory Results:** [Relevant laboratory values including full blood count, metabolic panel, and coagulation studies] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Microbiology results and culture findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Intake and Output:** [24-hour fluid balance including urine output and nasogastric output] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Nutritional status and feeding tolerance] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Assessment:** [Clinical assessment of the patient's current condition and stability] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) [Response to current therapies] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Identification of active problems] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Plan:** [Ventilator management plan] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Haemodynamic support adjustments] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Medication changes or additions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Monitoring parameters and frequency] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Planned procedures or interventions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Goals for the day] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)