CLINICAL DOCUMENTATION TIPS
Nidhi Shah, MD; Sahar Ahmad, MD
Format of a MICU progress Note:
Hospital Day#
MICU Day#
Ventilation Day#: Note if untubated or reintubated
Reason for MICU Admission: One liner as to why patient
was admitted/upgraded to ICU
Vasopressors/Inotropy: List any drips and rate they are
running at. These are included but not limited to
norepinephrine (levophed), vasopressin, phenylephrine
(neosynephrine), epinephrine, dopamine, dobutamine,
milrinone.
Sedatives: List any drips and rate they are running at.
These are included but not limited to propofol, fentanyl,
dexmedetomidine (Precedex), midazolam (Versed), ketamine
Paralytics: List any drips and rate they are running at.
These are included but not limited to cisatracurium (Nimbex)
and Rocuronium
Antibiotics: Include antibiotics/antifungals/antivirals patient
is currently on with dates started as well as dates of recently
completed antibiotic course
HPI Hospital Course:
Brief summary of hospital course and pertinent events in ICU.
Overnight Events:
Document overnight events and any events reviewed with
nursing staff.
AM Events:
Document AM events and any events reviewed with nursing
staff
Vital Signs:
Tmax or Tmin
HR: Include ranges over past 24 hours
RR: Include ranges over past 24 hours
SBP: Include ranges over past 24 hours
DBP: Include ranges over past 24 hours
MAP: Include ranges over past 24 hours
Pulse Ox at specific FiO2
Tmax
Ventilator Mode: Options include but are not limited to
VolAC, PressureAC, APRV, SIMV, Pressure Support. If on
Pressure support note settings (10/5, 5/5 etc.)
Ventilator Settings: Document settings as applicable
based on mode. Commonly in MICU patients are on volAC
with applicable settings of TV: RR: FiO2: PEEP. In COVID ICU
patients may be on APRV where Thigh, Tlow, Phigh and Plow
are appropriate settings to note.
ABG: Report in the following format pH/pCO2/pO2/HCO3
P/F ratio: pO2/FiO2
P-peak: Can be obtained from ventilator
P-plateau: Cannot be directly obtained from ventilator.
Need to perform inspiratory hold maneuver. DO NOT do
unassisted. Obtain help from either MICU fellow or respiratory
therapist.
Labs: Labs from the past 24 hours should auto-populate
Radiology: zz*Radiology should populate radiology
impressions from the past 24 hours
Microbiology: Include relevant culture speciation
Pathology: Include relevant pathology
Assessment: 1-2 line statement consolidating what is
acutely wrong and why. Do not re-iterate the HPI.
Plan:
Although notes can be documented in a systems based
format, prioritize presenting from most active issue to least
active issue.
List issues and plan for the day
1. Problem #1
2. Problem #2
3. Problem #3
Fluids: Document Current IVF patients are on. Can be
continuous or intermittent.
Volume Status: Options include Hypervolemic, Hypovolemic
or Euvolemic
Electrolyte: Document either “addressed’’ or “Will replete K,
Mag, Phos’’
Nutrition: Document if patient is on PO diet, Tube feeds, +/-
free water boluses, NPO or any other diet
Access: Document in the following way
Midline: Right/Left, Location, Date inserted
Arterial Line: Right/Left, Location, Date inserted
Central Line: Right/Left, Location, Date inserted
Interosseous: Right/Left, Location, Date inserted
PIV: Right/Left, Location, Date inserted
Volume
MICU Quality Measures
Antibiotic Stewardship: Document “antibiotics reviewed
for de-escalation”, “antibiotics discontinued based on clinical
status and/or microbiology data” or N/A
DVT ppx: Options include: lovenox subQ, heparin subQ,
SCDs, Other (heparin gtt, argatroban gtt, Eliquis, Xarelto
etc.), None (If None please document reason i.e acute blood
loss anemia suspected, at risk for brain hemorrhage etc.)
GI ppx: PPI, None, or Not indicated
Ventilator precautions bundle: Document if ordered. Yes,
No or N/A
Activity: Ad lib, As tolerated, Out of bed to chair, Bed Rest,
Other
Foley: Yes, No (If yes- explain need: AKI needs strict I/O,
shock needs strict I/O, cannot be turned & cleaned routinely
due to instability etc.)
Nursing Report: Can document “To be received during
rounds” Topics to be addressed with RN include: Sedation,
RASS, Is and Os, Tube Feed rate (at goal? Residuals?), PUP in
place, FS monitoring, Diet ordered?, Speech and swallow
pending?, Bowel movement Y/N?, Restraints/whether or not
still necessary, Mobility planned for the day. Level of nursing
care recommended (MICU, ICR, floor)
Code Status: Full Code, DNR/DNI, DNR, Comfort Care,
Attending Order placed Y/N
HCP or Surrogate Family Decision
Representative: Document HCP/NOK and contact
information
Disposition: Remains in need of ICU level of care,
Downgrade to ICR, Downgrade to general medical floors,
Downgrade to specialty floor: Renal, Medical Oncology,
Urology, other
Nursing Orders to be Reviewed: Can document
“Addressed” or specifics based on conversation with RN
