Note Writing in the Neuro ICU

Daily Progress Note:  Must be complete and systems based.  Responsible use of copy/paste.  Notes need to be detail oriented and thorough.  Co-signer is the ICU attending.   Included should be:

1.  HPI:  you should write this in your own words which can then be used on your daily notes.  Do not cut and paste HPI from other notes, especially when initial notes are from the emergency department, where history is often limited

2.  24-hour events:  what has happened since yesterday.  Test results, major events, etc..

3.  Physical exam:  this includes vital signs and all systems.  ICU patients need thorough physical exams

4.  Pertinent labs/imaging

5.  Assessment and plan laid out by system:

a.  Neuro:  EVD/ICP, AEDs, EEG

Example:  IVH, now HD#2 s/p intraventricular tPA.  Neuro exam remains stable, no seizures on 24-hour EEG.

–          list plan from here…

b.  Pulmonary: ventilator settings/changes, pulmonary toilet, oxygen, etc.

c.  CV:  BP goals, meds, gtts, EKGs, echo

d.  FEN/GI:  electrolytes, IVF, po vs enteral vs parenteral feeds including rates

e.  Renal:  UO, AKI, CKD

f.  Endocrine:  insulin, blood sugar goals, other endocrine issues/meds

g.  ID:  current infections, cultures outstanding, antibiotics (dose and intervals)

h:  Proph:  VAP, H2/PPI, SCDs, IVC filter

i:  Lines:  what, where, how long

j:  Dispo:  plan, time frame


Transfer/Discharge Summary:

1.  Date of Admission and Date of transfer

2.  Admitting Diagnosis

3.  D/C diagnosis, for d/c patients

4.  Any secondary diagnoses

5.  Procedures done up to this point (surgeries, lines, etc…)

6.  Consultations

7.  HPI

8.  Hospital course:  needs to include all important points of hospital stay including on what HD things occurs

9.  Disposition:  ie.. downgrade to neurology stroke or d/c to LTACH

10.  If being discharged:

– d/c meds, d/c instructions (follow-up)