ICU daily note

[Date of review] Patient seen by [name of clinician and qualification] [Name and Age of patient followed by number of days in ICU.] [Diagnosis and reason for ICU admission] [Background history (Describe in detail, only include relevant background history only if explicitly mentioned in the transcript or contextual notes.)] Current issues list: [Progress since admission list (list and describe in detail, only include progress since admission only if explicitly mentioned in the transcript or contextual notes)] Resuscitation status (Describe in detail, only include resuscitation status only if explicitly mentioned in the transcript or contextual notes.) Examination: Airway [Maintaining on own, intubated, tracheostomy or mask] Breathing [Chest Auscultation Ventilation Mode Fio2 PS PEEP ABG Ph Po2 Pco2 Hco3 Chest X ray or CT findings ] Circulation [CRT, MAP, BP HR Lactate Peripheral pulses and edema Inotrope or Vasopressors dose Fluid balance PPV/SVV Echo/ECG findings Trop T and BNP] CNS. [Sedation type and dose GCS or RASS Score Delirium Pupils Moving all limbs to painful stimulus CT brain findings] GIT. [Abdomen on examination Bowel sounds present or absent Any drains and output Oral, NG or TPN feed Ng Aspirate 4 hourly ok or high Last Bowel motion on Liver function tests and Amylase Blood glucose levels Insulin infusion] Haematology [Hb platelet INR APTT Anti coagulants dose and type] Renal [Sodium Potassium Urea and Creatinine levels Urine output and fluid balance per 24 hrs Dialysis or Diuretics dose] Sepsis [WCC and CRP levels and trends, temperature Blood or urine culture results COVID or Flu swabs Any other cultures available Antibiotics name and days on Septic focus Lines CVC/Vascath/Arterial line days in situ] [Peripheries, Wounds or surgical incision sites healthy or infection suspected. (Describe in detail, only if explicitly mentioned in the transcript or contextual notes.)] [Any pressure sores] [Mobility] Plan: (select as appropriate) [Continue to ventilate or extubate. Target Po2 and Pco2 and wean ventilation Target MAP and wean inotropes/Vasopressors Target RASS and wean sedation Control delirium with Laxatives or change from TPN to NG/oral feed. Target Hb and platelet count. Target fluid balance, use fluids, albumin, diuretics or dialysis Start, stop or change dose of anticoagulants as needed De-escalate antibiotics. Drug cardex review Physio and mobilisation Investigation plan like ECG/CXR/CT/ specific bloods] [Name of clinician]