ICU Progress Note (Systems-Based)

• Overnight events:
• Significant changes:
• Procedures performed:

• Temp: ___°C / ___°F
• HR: ___ bpm
• BP: ___/___ mmHg (MAP: ___)
• RR: ___ breaths/min
• SpO₂: ___% on __
• I/O: In: ___ / Out: ___ / Net: __

• Lines: (PIV, PICC, central, arterial — site, date placed)
• Drains:
• Airway: (ET tube at ___ cm, trach — size, date)
• NGT/OGT:
• Foley:
• Other:

• Mode:
• FiO₂: ___ PEEP: ___ RR: __
• Tidal Volume: ___ mL (IBW: ___ kg → ___ mL/kg)
• Peak/Plateau/Driving pressure: ___/___ / __
• SpO₂: ___ Last ABG:

• (List all IV drips and rates)

• Na: ___ K: ___ Cl: ___ CO₂: ___ BUN: ___ Cr: __
• Glucose: ___ Ca: ___ Mg: ___ Phos: __
• WBC: ___ Hgb/Hct: ___/___ Plt: __
• PT/INR: ___ PTT: __
• LFTs:
• Lactate:
• ABG: pH ___ / PaCO₂ ___ / PaO₂ ___ / HCO₃ ___ / BE __

• CXR:
• CT:
• Echo:
• Other:

Neuro

• Mental status:
• Sedation (RASS goal: ___, current: ___)
• Pain (CPOT/NRS: ___)
• Assessment:
• Plan:

Cardiovascular

• Rhythm:
• BP: MAP goal __
• Vasopressors: (yes/no; agent, dose)
• Assessment:
• Plan:

Pulmonary

• Ventilator: (mode, settings as above)
• Oxygenation:
• Weaning eligibility (SAT/SBT screen today?):
• Assessment:
• Plan:

GI / Nutrition

• Bowel function:
• Tube feeds: (formula, rate, goal)
• PO diet:
• GI prophylaxis: (yes/no)
• Assessment:
• Plan:

GU / Renal

• Urine output: ___ mL/hr (24h total: ___)
• Creatinine trend:
• Electrolyte repletion:
• Assessment:
• Plan:

Heme

• Hgb: ___ (transfusion threshold ___)
• Anticoagulation: (yes/no; indication, agent, dose)
• DVT prophylaxis: (SCDs, heparin SQ)
• Assessment:
• Plan:

Infectious Disease

• Fever: (yes/no; Tmax ___)
• WBC:
• Culture results:
• Antibiotics: (agent, day ___, planned duration)
• Assessment:
• Plan:

Endocrine

• Glucose range:
• Insulin: (drip/SQ; target ___-___)
• Steroids: (yes/no; indication)
• Assessment:
• Plan:

MSK / Skin / Wounds

• Mobility/PT status:
• Wound care:
• Pressure injury prevention:
• Assessment:
• Plan:

Prophylaxis Checklist

• VTE prophylaxis
• GI prophylaxis (PPI/H2)
• HOB > 30°
• Oral care
• Foley removal assessment
• Restraints (if applicable — reassessment documented)

• Current care level: (Full / DNR-CCA / CMO)
• Anticipated LOS:
• Barriers to discharge:
• Goals of care discussion: (date, participants, summary)

• Note synthesized from chart review and direct patient assessment.*
• Not copied from previous note.*