ICU progress note template?

[suckerfree]

anyone know where I can get a good template that guides the writing of an ICU progress note? Thanks!

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[JayneCobb]

anyone know where I can get a good template that guides the writing of an ICU progress note? Thanks!

are you looking for an actual form template, or a free-hand type of template?

 

[suckerfree]

either/or. I just want something in hand before I start my ICU elective. I wrote a few ICU notes on my general surgery clerkship, but would like to just have something in hand so that I can write a note starting on day 1.

Peace!

 

[JayneCobb]

either/or. I just want something in hand before I start my ICU elective. I wrote a few ICU notes on my general surgery clerkship, but would like to just have something in hand so that I can write a note starting on day 1.

Peace!

Have you had a medicine month yet? From your post history I'm going to assume you have.

I'm personally of the opinion that an ICU note should be a pretty much the same as a medicine note.

Give me some time and I'll post a few variations which I use frequently. This is one of my projects I've trying to put together for the 3rd year students who will be rotating through with me anyways.

 

[JayneCobb]

Don't nit-pick the dx or the findings, it's only a very rough draft which I spent more time formating than thinking through.

I included in this version, the co-morbid conditions. I generally only include them if

1) they're important to dz process
2) first time I've seen pt
3) this is the H&P,
4) if I'm actively managing the condition (i.e. diabetes)​

My S) tends to be shorter than my normal floor note, but other than that, I'm of the opinion that the people in the unit are sicker and deserve more documentation. I can not tell you how very irritated I'd get when I rotated at one hospital in my 4th year would transfer a pt out from the unit and they had no H&P, the daily progress notes were templates with no legible writing on them, and the residents & attending were always "Too busy" to tell me what they did for the pt.

Just how I do it, there is no single way and mine certainly isn't the only.

 

[suckerfree]

I personally like your format better. I had been told when I was on Gen Surg that the alternative is to do an Subjective documenting all the details, then an Objective/A/P by organ system for the remainder of the note. I did not like that one at all!

Thank you very much. I look forward to the ICU elective very much. Because of the nature of my schedule, I am going to be doing it 2 weeks in the first half of the year, and the remaining 2 weeks after my interviews, so that I could fit in some other electives. Do you think interviewers are going to care if I did the elective for 2 weeks rather than 4 by the time they see me?

Thanks!

 

[JayneCobb]

I personally like your format better. I had been told when I was on Gen Surg that the alternative is to do an Subjective documenting all the details, then an Objective/A/P by organ system for the remainder of the note. I did not like that one at all!

I agree, I do not like showing all the details in the Subjective area. The only things I will put are the disclaimers (seen, examined, chart reviewed) and I will only list what the patient complains of or how he subjectively feels. Unless they're sedated, then I'll put moving all extremities, withdraws from pain, etc in 1 line or so.

Thank you very much. I look forward to the ICU elective very much.

The Unit is one of my favorite places to be, it's like Medicine on crack.

Because of the nature of my schedule, I am going to be doing it 2 weeks in the first half of the year, and the remaining 2 weeks after my interviews, so that I could fit in some other electives. Do you think interviewers are going to care if I did the elective for 2 weeks rather than 4 by the time they see me?

Thanks!

In my experience, most places understand that you will need time to rotate and many others will understand that most students want to rotate through several programs to evaluate them. But there are always people who are butts out there.

There is a physician named Lawrence L Weed who is one of experts on medical documentation. And if you can find a couple of books titled: Medical records, medical education, and patient care:, read it. I can not remember if I read Medical records, medical education, and patient care: The problem-oriented medical record or Medical records, medical education, and patient care;: The problem-oriented record as a basic tool, but I'm sure they are both good reads.

I'm still trying to figure out how to work in all the things in it which he suggests on how to make a great problem-oriented record. With the looming pay per performance system with insurance/mediwhatever, this will become increasingly important for our profession.

ETA: Wow, this post really makes me feel like a nerdy internist.