ICU Presentation (Progress)

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[link memo="ID" mark="ID"]
.    [link memo="Updates" mark="updates"]
.    [link memo="tele" mark="tele"]

[link memo="S" mark="subjective"]
.    [link memo="ros" mark="ros"]

[link memo="O" mark="objective"]
.   [link memo="Vitals" mark="vitals"]
.   [link memo="physical exam" mark="physical exam"]
.   [link memo="I&O" mark="I&O"]
.   [link memo="Labs" mark="labs"]

[link memo="calculate" mark="calculate"]


[mark name="ID"] [link memo="Top" mark="Top"]
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I D
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Name: [text default=""]
Age: [text default=""]
Date of Admission:      [text default=""]
Initial Chief Complaint: [text default=""]
Admission Diagnosis:    [text default=""]
ICU Day:                [text default=""]
ICU Diagnosis: [text default=""]
PMH: [textarea default=""]

[mark name="updates"] [link memo="Top" mark="Top"]
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U P D A T E S
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[textarea default=""]

[mark name="tele"] [link memo="Top" mark="Top"]
[comment memo="1.Check Tele"]

[comment memo="Any Events? Any VT?"]
[text default=""]
[comment memo="What was the event? VT? AFib?"]
[text default=""]
[comment memo="When?"]
[text default=""]
[comment memo="For How Long"]
[text default=""]

[comment memo="Was Pt. Symptommatic?"]
[text default=""]

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[mark name="subjective"] [link memo="Top" mark="Top"]

[textarea default="This morning, the patient reports feeling ''better''. Last pain score was 0/10. Reports an improved ''appetite and alertness''. Currently asymptomatic, tolerating current therapy w/o any reported side effects."]

[mark name="ros"] [link memo="Top" mark="Top"]
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R O S
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[textarea default="Otherwise negative except for mentioned in HPI"]

[mark name="objective"] [link memo="Top" mark="Top"]
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[mark name="vitals"] [link memo="Top" mark="Top"]
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V i t a l s
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T   [text default=""]\[text default=""]\[text default=""]
HR  [text default=""]\[text default=""]\[text default=""]
BP  [text default=""]\[text default=""]\[text default=""]
P   [text default=""]\[text default=""]\[text default=""]
RR  [text default=""]\[text default=""]\[text default=""]
O2  [text default=""]\[text default=""]\[text default=""]

[textarea default=""]

[link memo="Top" mark="Top"] [mark name="physical exam"]

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P . E
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Gen:    [text default="laying in bed"]
        [text default="NAD"]
HEENT:  [text default="NC/AT"]
        [text default="EOMI"]
        [text default="PERRL"]
        [text default="MMM"]
        [text default="OP clear"]
Neck:   [text default="supple"]
        [text default="no cervical LAD"]
[text default="!        Mild JVD"]
Heart:  [text default="regular rate"]
        [text default="regular rhythm"]
        [text default="normal S1"]
        [text default="normal S2"]
[text default="!        Systolic murmur in LLSB."]
Pulm:   [text default="CTA B/L"]
        [text default="no wheezes"]
        [text default="no crackles"]        
        [text default="No nasal flaring"]
Abd:    [text default="soft"]
        [text default="non-tender"]        
        [text default="non-distended"]
        [text default="active bowel sounds"]        
        [text default=""]        
        [text default=""]
        [text default=""]
Exts:   No edema
        No clubbing
        [text default=""]
        [text default=""]
Neuro:  A&Ox4
        normal speech
        motor grossly intact
        sensory grossly intact
        [text default=""]
        [text default=""]
        

[textarea default=""]
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I & O
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I   [text default=""] mL
O   [text default=""] mL
T   [text default=""] mL
UOP [text default=""] mL

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L A B S [link memo="Top" mark="Top"]
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C B C [link memo="Top" mark="Top"]

    [text default=""] [text default=""] [text default=""]
Wbc [text default=""]\[text default=""]\[text default=""]
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Rbc [text default=""]\[text default=""]\[text default=""]
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Hgb [text default=""]\[text default=""]\[text default=""]
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Plt [text default=""]\[text default=""]\[text default=""]
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C H E M [link memo="Top" mark="Top"]

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Na  [text default=""]\[text default=""]\[text default=""]
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K   [text default=""]\[text default=""]\[text default=""]

Ca  [text default=""]\[text default=""]\[text default=""]

Co2 [text default=""]\[text default=""]\[text default=""]

Cl  [text default=""]\[text default=""]\[text default=""]

Mg  [text default=""]\[text default=""]\[text default=""]

PO  [text default=""]\[text default=""]\[text default=""]

AG  [text default=""]\[text default=""]\[text default=""]

BUN [text default=""]\[text default=""]\[text default=""]

Cr  [text default=""]\[text default=""]\[text default=""]

GFR [text default=""]\[text default=""]\[text default=""]

Glu [text default=""]\[text default=""]\[text default=""]

A1c [text default=""]\[text default=""]\[text default=""]

PT  [text default=""]\[text default=""]\[text default=""]

PTT [text default=""]\[text default=""]\[text default=""]

INR [text default=""]\[text default=""]\[text default=""]

DD  [text default=""]\[text default=""]\[text default=""]

Lac [text default=""]\[text default=""]\[text default=""]

L F T 

AST     [text default=""]\[text default=""]\[text default=""]

ALT     [text default=""]\[text default=""]\[text default=""]

ALK     [text default=""]\[text default=""]\[text default=""]

DB      [text default=""]\[text default=""]\[text default=""]

IDB     [text default=""]\[text default=""]\[text default=""]

TB      [text default=""]\[text default=""]\[text default=""]

Alb     [text default=""]\[text default=""]\[text default=""]

Prot    [text default=""]\[text default=""]\[text default=""]

AMMONIA [text default=""]\[text default=""]\[text default=""]

        [text default=""]\[text default=""]\[text default=""]
        
        [text default=""]\[text default=""]\[text default=""]
        
        [text default=""]\[text default=""]\[text default=""]
        
BLOOD GAS

PH      [text default=""]\[text default=""]\[text default=""]


PCO2    [text default=""]\[text default=""]\[text default=""]

PO2     [text default=""]\[text default=""]\[text default=""]

HCO3    [text default=""]\[text default=""]\[text default=""]

OXHGB   [text default=""]\[text default=""]\[text default=""]

CBXYHGB [text default=""]\[text default=""]\[text default=""]

METGB   [text default=""]/[text default=""]/[text default=""]

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I M A G I N G [link memo="Top" mark="Top"]
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X r a y [link memo="Top" mark="Top"]
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[comment memo="Name"][text default=""]
[comment memo="Results"][textarea default=""]

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E c h o / U s [link memo="Top" mark="Top"]
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E k g [link memo="Top" mark="Top"]
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P R O C E D U R E S [link memo="Top" mark="Top"]
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d88P.....888.ssessment..

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..8888888b.....
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#A C T I V E [link memo="Top" mark="Top"]
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$C H R O N I C [link memo="Top" mark="Top"]
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R E S O L V E D [link memo="Top" mark="Top"]
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O T H E R [link memo="Top" mark="Top"]
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#Consults [link memo="Top" mark="Top"]
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F A S T . H U G S . B I D . D / C [link memo="Top" mark="Top"]
.................................
 
F - Food
- [text default="Renal Diet/Na Controlled"]

A - Analgesia
- [text default="Acetaminophen"]

S - Sedation
- [text default="None"]

T - ThromboPPx
- [text default="Heparin"]

H - Head of Bed Elevation 
- [text default="Yes"]

U - Ulcer PPx
- [text default="Pantoprazole @@@"]

G - Glycemic Control
- [text default="Goal 140-180 @@@"]
- [text default="Meds: None Required"]

S - Spontaneous Breathing Trial
- [text default="None Required @@@"]

B - Bowel Reg
- [text default="None Required @@@"]

I - IV+Lines/Drains/Catheter
- [text default="
- IV+Lines: 1x Peripheral IV
- Drains: None
- Catheter: Condom"]

D - De-escalating Antibiotic(s)
- [text default="None Required @@@"]

D - Dispo
- [text default="stable @@@"]

C - Code Status
- [text default="Full @@@"]

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C O N T A C T S
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[textarea default=""]

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S I G N A T U R E
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[textarea default="
I am under supervision of attending @@@@.

CAPT. Drew (Andrew) J. La'Pelusa Staples, MD, MS
USARMY, MC
CDU IM PGY1"]




[shorthand name="#AKI" value="
#AKI 
-Creatinine up to 1.64 today 
-ATN vs. pre-renal vs. pulmonary renal syndrome
- Will place foley
- Order urine lytes, eos
- Renal US
- Nephrology consult"]


[shorthand name="#CAD3"]
#CAD - extensive, 3 vessel, hx of STEMI x2 (2002, 2017) s/p AICD placement
-Per cardiology, poor candidate for stenting and CABG
- Continue heparin gtt
- Continue aspirin \
[/shorthand]



[shorthand name=".#cardiogenic shock"]
#Cardiogenic shock
- Continue milrinone per cardiology recs
- Trend lactates
- Cardiology following
- Unclear endpoint for milrinone titration - will discuss with cardiology
[/shorthand]



[shorthand name="#ESRD"]
#ESRD on HD, currently undergoing HD daily for volume overload
- Next HD session tomorrow
[/shorthand]



[shorthand name="#nutrition"]
[/shorthand]


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[mark name="calculate"] [link memo="Top" mark="Top"]
                                               

Note - this form uses SOAPnote Shorthand. For a table of all phrases click View > Data Dictionary


Top

Top


ID
. Updates
. tele

S
. ros

O
. Vitals
. physical exam
. I&O
. Labs

calculate


ID Top
..................
I D
..................

Name:
Age:
Date of Admission:
Initial Chief Complaint:
Admission Diagnosis:
ICU Day:
ICU Diagnosis:
PMH:


updates Top
..................
U P D A T E S
..................


tele Top
1.Check Tele

Any Events? Any VT?

What was the event? VT? AFib?

When?

For How Long


Was Pt. Symptommatic?


..d8888b..........................................
d88P..Y88b........................................
Y88b..............................................
."Y888b...........................................
...."Y88b.........................................
......"888........................................
Y88b..d88P........................................
."Y8888P"..ubjective .............................
..................................................
subjective Top



ros Top
.....................
R O S
.....................




objective Top
..d88888b.........................................
d88P" "Y88b.......................................
888.....888.......................................
888.....888.......................................
888.....888.......................................
888.....888.......................................
Y88b...d88P.......................................
."Y88888P"..bjective..............................


vitals Top
.....................
V i t a l s
.....................


T \\
HR \\
BP \\
P \\
RR \\
O2 \\



Top physical exam

.....................
P . E
.....................

Gen:

HEENT:




Neck:


Heart:




Pulm:



Abd:






Exts: No edema
No clubbing


Neuro: A&Ox4
normal speech
motor grossly intact
sensory grossly intact





TopI&O
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I & O
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I mL
O mL
T mL
UOP mL

Toplabs
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L A B S Top
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C B C Top


Wbc \\



Rbc \\



Hgb \\



Plt \\


C H E M Top


Na \\


K \\

Ca \\

Co2 \\

Cl \\

Mg \\

PO \\

AG \\

BUN \\

Cr \\

GFR \\

Glu \\

A1c \\

PT \\

PTT \\

INR \\

DD \\

Lac \\

L F T

AST \\

ALT \\

ALK \\

DB \\

IDB \\

TB \\

Alb \\

Prot \\

AMMONIA \\

\\

\\

\\

BLOOD GAS

PH \\


PCO2 \\

PO2 \\

HCO3 \\

OXHGB \\

CBXYHGB \\

METGB //

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M i c r o Top
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//

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I M A G I N G Top
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X r a y Top
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Date//
Name
Results


Date//
Name
Results


Date//
Name
Results

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C t Top
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Date//
Name
Results


Date//
Name
Results


Date//
Name
Results


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E c h o / U s Top
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Date//
Name
Results


Date//
Name
Results


Date//
Name
Results


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E k g Top
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Date//
Results


Date//
Results


Date//
Results




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P R O C E D U R E S Top
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Top
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...d88P..888............
..d88P...888............
.d8888888888............
d88P.....888.ssessment..



...............
..8888888b.....
..888...Y88b...
..888....888...
..888...d88P...
..8888888P"....
..888 .........
..888..........
..888.lan......

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#A C T I V E Top
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#

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O T H E R Top
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#Consults Top
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F A S T . H U G S . B I D . D / C Top
.................................

F - Food
-

A - Analgesia
-

S - Sedation
-

T - ThromboPPx
-

H - Head of Bed Elevation
-

U - Ulcer PPx
-

G - Glycemic Control
-
-

S - Spontaneous Breathing Trial
-

B - Bowel Reg
-

I - IV+Lines/Drains/Catheter
-

D - De-escalating Antibiotic(s)
-

D - Dispo
-

C - Code Status
-

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C O N T A C T S
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S I G N A T U R E
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calculate Top

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