ICU Daily Ward Round → Clinical Note Generator

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ICU DAY & ISSUES

ICU Day:

List of issues:

AIRWAY

Own COETT Trache Other

Other airway details:

BREATHING

Respiratory support / ventilation mode:

PRVC SIMV Automode VS CPAP-PS NIV NHF Simple face mask Room air Other

FiO₂

%

Pressure support

PEEP

RR

Tidal volume

mL

SpO₂

%

Tracheal secretions:

None Minimal Moderate Significant

Secretion description:

Respiratory examination:

CIRCULATION

HR:

BP:

Cardiovascular support:

Cardiovascular examination:

NEUROLOGY

Sedation:

Propofol Alfentanil Clonidine Midazolam Other

Neurological examination:

RENAL & ELECTROLYTES

Urine output:

mL/hr

Fluid balance, last 24 hours:

Fluid balance since admission:

U&Es

Na

K

Urea

Creat

Mg

PO₄

CRRT?

Yes No

CRRT comments:

Any other renal or electrolyte comments:

GASTROINTESTINAL

Nutrition:

Absorbing feed?

Blood sugars:

VRII insulin?

Yes No

Any comments:

HAEMATOLOGY

Hb:

Platelets:

INFECTION

Antibiotics:

Current temperature:

°C

Fever >38°C in last 24 hours:

Procalcitonin:

LINES

Comment on lines and number of days in situ:

HOUSEKEEPING

Please confirm the following have been checked and considered:

VTE prophylaxis reviewed

Yes No N/A

PPI reviewed

Yes No N/A

Sedation hold considered

Yes No N/A

Extubation readiness assessed

Yes No N/A

Lines still required

Yes No N/A

IMPRESSION & PLAN

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