ICU DAILY PROGRESS/SOAP NOTE

ICU DAILY PROGRESS/SOAP NOTE
 
DOI:
PBD:
Burn info:
MOI: 
 
Procedure List 
MM/DD Surgery w injury location 
MM/DD Surgery w injury location 
 
Subjective: 
 
 
 
Pain Score (1-10 Visual Assessment Scale if unable to voice) 
_▼
 
 
Objective: 
Vitals: (existing dot phrases)
Ventilated? 
_▼
 
 
 
Physical Exam: 
(existing dot phrase for physical exam) 
 
Burn Wounds: (complete for each anatomical location)
  Wound conversion? 
_▼
 
  % Epithelialization: 
  Infection? 
_▼
 
 
 
Labs: (existing dot phrases)
 
Diagnostics:
 
Medication List: 
[* Medication List]
 
 
Assessment and Plan
Assessment etc. (age, gender, %TBSA, burn depth, MOI)
 
  #Burn Injuries 
    (list under each anatomic location w burn injury)
    %TBSA: free text 
    Burn depth: 
_▼
 
    Healing Status: (i.e. healed, % epithelialized, grafted) 
    Grafted: 
_▼
 
       Type-
      Donor site-
    Infection: 
_▼
 
    % of wound closure (if applicable): 
 
Head/face:
Neck:
Anterior trunk 
Posterior trunk 
Breast:
RUE:
LUE:
R hand:
L hand:
RLE:
LLE:
R foot:
L foot:
Buttocks:
Genitals:
 
#Burn
 
 
#Dressings 
_▼
 
 
#Neuro
-pain:
-sedatives:
-antipsychotics 
 
#CV
 
 
#Pulm 
ventilator status: 
pulmonary toilet:
 
#FEN/GI
fluids-
diet-
enteral access-
 
#GU
UOP
foley status: 
_▼
 
 
#Heme/ID
Abx: 
Infection

#MSK
PT/OT: 
_▼
 
weight bearing status: 
_▼
 
splints/casts:
 
#PPx
DVT ppx: 
_▼
 
GI ppx: 
_▼
 
 
#Pain
 
Requires ongoing hospitalization for:
_▼
 
 
consulting teams: 
 
Discharge Dispo:_▼