ICU Daily Ward Round → Clinical Note Generator

Complete the relevant fields, generate the note, then copy the formatted text into the patient record.

ICU DAY & ISSUES

ICU Day:

List of issues:

AIRWAY

Own COETT Trache Other

Other airway details (optional):

BREATHING

Respiratory support / ventilation mode:

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

FiO₂

%

Pressure support

PEEP

Peak pressure

Tidal volume

mL

RR

SpO₂

%

Blood gases:

Additional parameters (optional):

Tracheal secretions:

None Minimal Moderate Significant

Secretion description:

Respiratory examination:

CIRCULATION

HR:

BP:

Cardiovascular support:

Yes No

Support details:

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

GI examination:

Nutrition:

Absorbing feed?

Bowels:

Blood sugars:

VRII insulin?

Yes No

Any comments:

HAEMATOLOGY

Hb:

Platelets:

WCC:

INFECTION

Antibiotics:

Current temperature:

°C

Fever >38°C in last 24 hours:

Yes No

Highest temperature in last 24 hours:

°C

PCT/CRP:

Any positive microbiology:

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