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How to Write an ICU Note

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Overview






Patients in the intensive care unit (ICU) are without question the sickest in the hospital and require a ton of care. Unlike a normal patient note, which is generally brief and written in the SOAP format, the ICU note is more thorough and exhaustive. Below is a discussion of how an ICU note should be organized so that important information is not missed. Please note that this is not the only way to organize an ICU note, but it is a way that many units use because it is extremely thorough and organized.

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Organize by Systems

The beginning of any ICU note should always have the patient's name, date, time, hospital day, post operative day (if in the surgical ICU), and lines going into or out of the patient.

(1) Patient's name
(2) Date and time
(3) Hospital day
(4) Post operative day
(5) Lines (include any tube going into or out of the patient)
(6) Drips (often abbreviated "gtts", includes any medicines "dripping into the patient through an IV)

Unlike normal floor notes, which are organized by problem, ICU notes are most commonly organized by body system. The systems are usually written in the following order:

- Neurological
- Cardiovascular
- Respiratory (pulmonary)
- Renal
- Fluids, electrolytes, nutrition (FEN)
- Infectious disease
- Hematology
- Gastrointestinal
- Endocrine
- Psychiatric
- Prophylaxis

Let's talk about what information should be included in each system.

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Neurological

At the bare minimum the neurological part of the note should include the patient's alertness and orientation (ie: "AAOx3"), and their Glasgow coma scale (GCS) score. If the patient is in the neuro-ICU the exam should be more thorough and include the GCS score by component, as well as a neurological exam.

Along with the physical exam, a common question asked by neuro-intensivists is "what can the patient do?" Do they follow all commands? Do they withdraw to pain? Are they decorticate? Decerebrate? Give a description of what the patient can do.

Some patients in the ICU may have an external ventricular drain (EVDs) or lumbar drain used to remove cerebrospinal fluid. If this is the case the output of the EVD or lumbar drain should be recorded. EVDs are set to a specific height above the tragus of the ear; this number is important to record as well.

Finally, specific medicines related to neurological disease should be added. Any medications used to sedate or paralyze the patient should also be included as they may confound the physical exam findings.

To recap, the neurological section should include the following elements:

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Cardiovascular

In addition to physical exam findings, the cardiovascular section should start off with the heart rate, rhythm, blood pressure, and central venous pressure. Patients with significant cardiovascular disease may have a pulmonary artery catheter (aka: Swan Ganz catheter). The data obtained from it should also be included: pulmonary artery pressure, pulmonary artery wedge pressure, cardiac output, cardiac index, central venous pressure (can also be obtained from a normal central line), and stroke volume.

The cardiovascular section of the note should also include what drips the patient is on to control blood pressure.

To recap, the cardiovascular section should include:

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Respiratory (Pulmonary)

In addition to physical exam findings, the most important thing to include in this section are the ventilator settings. It should be organized in the following way: mode, FiO2, tidal volume, patient's respiratory rate, ventilator's rate, peak end expiratory pressure (PEEP), pressure support, peak airway pressure.

After the ventilator settings, the patient's oxygen saturation should also be stated.

Any laboratory data specific to the pulmonary system is given next. This commonly includes arterial blood gas values written in the following order: pH, PaO2, PaCO2, and HCO3. Chest x-ray results should also be written here.

To recap, the respiratory portion of the note should include:

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Renal

The renal section includes an evaluation of the patient's kidney function. The first piece of data that should be recorded are the "in and outs". The "ins" include the total amount of fluid the patient has received intravenously and orally. The "outs" include the total amount of urine the patient has made. The urine output should be recorded in mL/kg of body weight per shift and over the last 24 hours.

Laboratory data that should be written in the renal section includes the creatinine, blood urea nitrogen (BUN), urinalysis, urine microscopy, and any imaging studies specific to the urinary tract. You may also need to calculate and include the fractional excretion of sodium.

To recap, the renal section of the note should include:

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Fluids, Electrolytes, and Nutrition (FEN)

The fluids, electrolytes, and nutrition section should have what fluids, both intravenously and orally, the patient is receiving. The patient's electrolytes should also be recorded in this section. The most common electrolytes that are measured are sodium, potassium, chloride, bicarbonate, phosphorus, calcium, and magnesium. In addition, the patients diet, either orally or intravenously should be discussed along with their nutritional status (usually measured by albumin or prealbumin levels).

To recap the fluids and electrolytes section should include:

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Infectious Diseases

The infectious diseases section should always begin with the maximum temperature over the last 24 hours followed by the current temperature.

After that the patient's white blood cell count should be mentioned. If there are any pending or final culture results they should be included in sequential order. Common data recorded include blood, urine, and sputum cultures. Sometimes cerebrospinal fluid cultures will also be available.

Finally, all antibiotics the patient is receiving should be listed along with how many days they've been on each one.

To recap, the infectious disease section should include:

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Hematology

Physical exam findings such as bruising, petechiae, oozing from surgical incisions should be mentioned.

The hematology section should have the hemoglobin, hematocrit, platelet count, prothrombin time, INR, and partial thromboplastin time. Other values that are less common, but may be present include iron studies, d-dimer results, fibrinogen levels, and mixing studies.

Since blood clot formation is a huge concern in hospitalized patients, any results related to this should be included. Studies such as lower extremity dopplers, chest CT or ventilation perfusion scans should be included in this section.

To recap, the hematology section should include:

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Gastrointestinal

The gastrointestinal section is devoted to the patient's bowel function. A discussion of how the patient is being fed and what is being fed to the patient is written in this section. For example, oral versus intravenous feedings. Is a nasogastric tube present?

Laboratory data that should be included here are the patient's albumin level (measured every few weeks) and the patient's prealbumin level (usually measured every 48 hours).

Physical examination findings of the gastrointestinal tract should be written as well. They may include abnormal bowel sounds, enlarged liver or spleen, ascites, or blood in the stool.

To recap, the gastrointestinal section should include:

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Endocrine

The most important thing for the endocrine section is the blood sugar results. Other common values that are often ordered for ICU patients include serum osmolality. Any medications used to control glucose levels such as insulin drips or hypoglycemic agents should be recorded.

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Psychiatric

The psychiatric portion of the note is often neglected or omitted, but is an important component to at least think about. Many psychiatric issues will be dealt with once the patient is out of the ICU.

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Prophylaxis

The prophylaxis section is very important! Most patients in the ICU will be on a medicine to decrease the risk of developing gastric ulcers, as well as several methods to prevent deep venous thrombosis and pulmonary embolism. Any prophylactic measure should be listed and addressed during rounds.

The prophylaxis section includes:

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Overall

There are different ways to organize an ICU note. By far the most common way is to organize it by systems. However, various services (ie: neurosurgery, cardiothoracic, etc) will have specific they want data presented depending on what information is most important to them.

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The SOAP format is written with four different components. The "S" stands for subjective and includes any patient complaints. The "O" stands for objective and includes vital signs, physical exam, and any laboratory and/or imaging data. The "P" stands for plan, or what you're going to do to treat the patient.