Writing ICU Notes

[Yah-E]

Is there a link to a good ICU note sample or a ICU note template/outline? Thanks!

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[DOtobe]

Don't know of any particular websites, but I remember this old thread about ICU notes (and the rotation in general)

ICU thread

 

[raspberry swirl]

you probably already have been told this, but just in case ... i was always taught to arrange the A/P by system- cards, pulm, endo, g/u, etc ... including every single system even if there was no problem (and writing "No Issue" next to it), that way you can be sure you haven't missed anything. for us, the rest of the note (s and o) were always the same as any progress note.

 

[CaptMorgan]

Here's a decent ICU website:
http://meded.ucsd.edu/isp/2001/sicu/splash.html

 

[Mumpu]

A lot of ICU patients are better served with a problem-based rather than a systems-based note. That EtOH withdrawal or GIB really doesn't need a daily discussion of 15 different organ systems.

 

[DOtobe]

A lot of ICU patients are better served with a problem-based rather than a systems-based note. That EtOH withdrawal or GIB really doesn't need a daily discussion of 15 different organ systems.

I was told by one of my attendings to write notes in a problem-based, rather than systems-based, fashion, because this is how the insurance company is billed (by problem), and you need documentation that each of the problems you bill for exist.
System-based is good because it is a way to check yourself to make sure you are looking at the whole picture, but problem-based is the way the hospital gets paid...money makes the hospital world go round

 

[southerndoc]

I was told by one of my attendings to write notes in a problem-based, rather than systems-based, fashion, because this is how the insurance company is billed (by problem), and you need documentation that each of the problems you bill for exist.
System-based is good because it is a way to check yourself to make sure you are looking at the whole picture, but problem-based is the way the hospital gets paid...money makes the hospital world go round

Even better is a system/problem-based approach. Example:

1. Cardiovascular: MI
2. Cardiovascular: HTN
3. Cardiovascular: Preventive

 

[VentdependenT]

dont forget that the note is ultimately for YOU.

I write systems based note then follow it up with a plan which always includes DISPO and DVT prophylaxis/ttx. Emphasis on DISPO.

 

[DOtobe]

Emphasis on DISPO.

Exactly.

Every day on ICU rounds, the attending's main question is "can this patient be transferred out?"

 

[Droopy Snoopy]

dont forget that the note is ultimately for YOU.

I write systems based note then follow it up with a plan which always includes DISPO and DVT prophylaxis/ttx. Emphasis on DISPO.

Also lines/tubes, nutrition, and code status. I agree that a systems-based approach works best for the in-training setting. Even if the patient isn't a trainwreck it helps to think in terms of comprehensive care all the time or else your mind starts taking shortcuts. Eventually sure you get to the more billing-friendly way of doing things, but that's a terrible reason to change the way you document as an intern. Nobody should be billing based solely off your note anyway.

 

[jdh71]

Even better is a system/problem-based approach. Example:

1. Cardiovascular: MI
2. Cardiovascular: HTN
3. Cardiovascular: Preventive

This.

But I don't list CV over and over. I address each diagnosis/problem with that system.

Like this . . .

1. Neuro - Massive R MCA stroke, s/p craniotomy, POD #8, cont ASA, statin, BP meds.
2. Pulm - Resolving ARDS, cont APRV; VAP, culture positive for E coli, will cont levaquin day 5 of 14
3. CV - HTN well controlled on lisinopril; Afib rate controlled on amiodarone

Etc. I always also address nutrition, usually with electrolytes, and prophylaxis.