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**
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