What is the proper format for writing notes in the Intensive Care Unit (ICU)?

Proper Format for Writing Notes in the ICU

ICU notes should follow a structured format that includes patient demographics, vital signs, health history, review of systems, physical examination, assessment, and a detailed management plan to ensure comprehensive documentation and improve patient outcomes. 1

Essential Components of ICU Notes

Patient Identification and Demographics

• Include patient name, identification, contact information, age, and weight 1
• Document the name of the patient's primary care provider or medical home 1
• Record admission date, time, and reason for ICU admission 2

Vital Signs and Monitoring Data

• Document heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 1
• Include ventilator settings and parameters for intubated patients 2
• Note if vital signs cannot be obtained due to patient non-cooperation 1

Health History

• Document allergies and previous adverse drug reactions 1
• List all medications including prescription, over-the-counter, herbal supplements, and illicit drugs 1
• Record relevant diseases, physical abnormalities, and previous hospitalizations 1
• Document pregnancy status for females of childbearing age 1

SOAP Format for ICU Notes

The SOAP (Subjective, Objective, Assessment, Plan) format is widely recommended for structuring ICU progress notes: 3, 4

Subjective

• Document patient's reported symptoms and concerns 4
• Include information from family members when patient cannot communicate 2
• Record sleep quality, pain levels, and other subjective experiences 1

Objective

• Document physical examination findings relevant to the patient's condition 1
• Include laboratory results, imaging findings, and other diagnostic test results 4
• Record medication administration and patient's response to treatments 1

Assessment

• Identify and prioritize active problems 3, 4
• Document clinical reasoning and differential diagnoses 3
• Include ASA classification for procedural cases 1

Plan

• Detail specific interventions for each identified problem 4
• Include both pharmacological and non-pharmacological therapies 1
• Document education provided to patient/family and follow-up plans 5

Additional ICU-Specific Documentation Requirements

Daily Goals Documentation

• Implement a daily goals sheet to improve communication between healthcare team members 2
• Use a static sequential with verification format where items are read off and team members respond with status 2
• Document clear tasks for the day to ensure all team members understand the patient's care plan 2

Family-Centered Care Documentation

• Document family conferences and information shared with family members 2
• Consider implementing ICU diaries to reduce family member anxiety, depression, and post-traumatic stress 2
• Record the provision of informational leaflets to family members about the ICU setting 2

Procedural Documentation

• Include time-based records of administered drugs during procedures 1
• Document "time out" confirmation of patient name, procedure, and site 1
• Record monitoring data including level of consciousness and vital signs during procedures 1

Specialized Documentation for ICU Patients

Delirium Assessment and Management

• Document delirium screening results and interventions 2
• Note orientation aids, communication improvements, and environment modifications implemented 2
• Avoid documenting prophylactic haloperidol for ventilated patients as it shows no effect on delirium outcomes 2

Early Mobilization Documentation

• Document early mobilization efforts started within the first few days in ICU 2
• Record the type of mobilization performed (passive, assisted, or active exercises) 2
• Note patient's response to mobilization and any complications 2

Ventilator Management

• Document ventilator settings, weaning parameters, and daily assessment for weaning readiness 2
• Record implementation of ventilator-associated pneumonia prevention interventions 2
• Note any complications related to mechanical ventilation 2

Common Pitfalls to Avoid in ICU Documentation

• Failing to document when vital signs cannot be obtained 1
• Omitting medication history that could interact with treatments 1
• Inadequate documentation of allergies and previous adverse reactions 1
• Not documenting baseline health status for comparison during treatment 1
• Failing to document family communications and involvement in care decisions 2

Checklist Implementation for ICU Documentation

• Use checklists to ensure comprehensive and consistent documentation 2
• Implement interdisciplinary checklists that empower nurses to verify physician compliance with best practices 2
• Re-evaluate and update checklists periodically based on new evidence and organizational experiences 2