MICU Note

[Pox in a box]

---

Members don't see this ad.

Does anyone have a template or can explain how to write a good MICU note? I want to have a good format and know what to do besides putting the problem list by systems.

 

[DOtobe]

The S/O part of an ICU note is the same as any other note, except a lot of the time the "S" portion will have to come from the nursing staff, since a lot of the patients are intubated and sedated and can't give you any subjective info. The "S" is basically any issues that occurred overnight.

Here is basically how I organize my A/P in my ICU notes:
1. Pulm: vent day #, vent settings, O2 sats, is pt ready to be weaned off of the vent? (i.e. low FiO2 values and low PEEP?), has pt tolerated weaning trials, on any breathing tx?
2. Cardio - has BP/HR been stable or unstable? Cardiac meds? Recent studies (echo, EKGs, etc)
3. Heme - H/H stable? DVT prophylaxis? What type of venous access/art lines and how old are the lines?
4. Renal - BUN/Cr (once again, stable or unstable?) UOP adequate?
5. GI - gastritis prophylaxis? Having BMs? Start bowel regimen if pt is on narcotics and has not had a BM.
6. ID - antibiotic day #, febrile or not in the past 24 hours? WBC count trend?
7. FEN - lytes normal or abnormal? Maintenance fluids? (what kind and at what rate?) Tube feeds? (what kind and what rate, and are they at goal?)
- by the way, FEN means fluids/electrolytes/nutrition - I hadn't seen this nomenclature until I started internship and didn't know what it meant at first.
8. Neuro - is pt sedated? Meds for pain control?
9. Endocrine - accuchecks controlled or not? Is pt on sliding scale/long acting insulin?

You should also document if you discussed the patient with family members (to avoid the family members saying "nobody discussed anything with me...")

God, that's long-winded, but I'm in the ICU right now, so this is how I am writing my notes every day...

 

[Sammich81]

I had 2 attendings in the MICU: one liked systems, one didn't. So I wound up doing this:

I started with a problem list to hit their most serious 4-6 issues. So after the subjective, labs, vent settings etc I would say for example "56 yo female HOD #12 w/pneumococcus bacteremia. Problems include
1. Sepsis: are we meeting early goal directed therapy (see critical care guidelines for UO, CVP, MAP, SvO2)? Antibiotics day? New culture results? Febrile/white count?
2. ARDS: how's vent wean going? Are we doing low tidal volume protective strategies?
3. Acute on chronic renal failure: Cr trends/dialysis yes no, etc

and so on.
Then I would do a quick run down of systems just to hit what you didn't already talk about. Sedation, fluids, nutrition, GI/DVT prophylaxis etc.

 

[Dr JPH]

ICU Day #
Problem List (HTN, DM, Met Alkalosis...)
Med List
Allergies
Code Status (important IMO)
Fluids/Nutrition
Vent Settings (include # days on vent)
Lines/Access (include # of days lines have been in)
Systems: Neuro, Cards, Pulm, GI, Gu, Endo, etc
Assessment/Plan (address everything in your problem list)

 

[PukiUki]

I too simply cover each system in my A/P: head to skin. This way you will cover everything. Such an A/P format is also great for complicated floor pts.