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:_▼
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