Documenting on an ICU Ward Round

OVERVIEW

• This page is a suggested approach to ICU ward round documentation
• Each site will usually have their own preferred way and things to include in their daily documentation
• Documentation will be different if you’re still on paper notes
• Don’t forget that patients notes are legal documents, and you have a legal responsibility to those notes (including editing or addendums!)

INTRODUCTION

We are taught many different approaches to documenting on a round. An ICU round ay require more information than you are used to adding into your notes. You may also be including information on machines / parameters that you’re not used to including (e.g. ventilator modes / settings, vasopressor and inotrope infusions etc)! If in doubt, just ask.

Don’t forget that accurate notes are VERY important and omitting details intentionally or unintentionally can have consequences.

A reminder. If you plan on editing a mistake or adding something in to a note to cover your ass — don’t (this has particular relevance to electronic notes). All electronic note systems I am familiar with (such as PowerChart from Cerner, eRIC / Metavision) have very easy ways that we can compare originals to edited notes — they are all timestamped and user stamped. Doctors have been reprimanded for editing notes and actually may be reported to AHPRA/the medical board for inappropriate conduct.

AN APPROACH

Start with who is on the round (e.g. Consultant / Registrar / RMO / Medical student), then include a summary line of the patient
e.g. ICU AM WR – Nickson / Pearlman / Blogs
67M day 8 ICU with necrotising gallstone pancreatitis with multi-organ dysfunction.

ISSUES
# Necrotising gallstone pancreatitis
# Type 1 respiratory failure
# Septic shock
# Renal failure on CRRT

PROGRESS
– Include in here things that may have happened since the last time you or your day/night team documented a ward round note
– E.g. night team administered 2 units of red cells, 300mg loading of amiodarone administered for AF now rate controlled etc.

EXAMINATION
A/B: Here you would also include ventilator modes / relevant bits and bobs
– e.g. ETT remains at 23cm at the teeth. SIMV-VC 500×12, FiO2 0.6, PEEP 10 / PS 10. Scant secretions. Good AE Throughout chest, no added sounds.
– also include here if they are on any inhaled agents such as Epoprostenol (Flolan) or Nitric Oxide to assist with oxygenation!
CVS: General cardio examination / or focussed. Add in any vasoactive agents and the rate they are running at and maybe a trend with that
– e.g. noradrenaline stable at 12mL/h (of 4mg in 50mL) with BP meeting targets of >100 / MAP >65, AF rate controlled between 80-100, amiodarone infusion running. Peripherally warm and well perfused. Dependent peripheral oedema.
CNS: Quick neurological examination relevant details, it may actually need to be quite detailed especially for neurocritical care patients. Also include here any sedative agents / analgesia infusions or PCAs running
– e.g. E4VTM6, RASS (Richmond Agitation and Sedation Score) 0, comfortable on Prop of 2mL/h, dexmedetomidine at 0.5microgs/kg/min and fentanyl of 10microgs/h. No new focal neurology. PEARL 3mm.
– You may also need to document things like EVD height and outputs, colour etc. If the EVD is open / closed etc. etc. (just ask if unsure)
GIT: Include NG/PEGs etc. as well as other drains, diet intake, bowel status
– e.g. NG feeds Nutrison Protein Plus running at 60mL/h, minimal aspirates, bowels opening daily, abdomen soft and not tender.
GUT: I tend to include CRRT here as well.
– e.g. IDC, oliguria remains with concentrated / cola coloured output ~10-20mL/h. CRRT ongoing, no issues running on CiCa (Citrate-Calcium) circuit, fluid balance close to -ve 2 litres.
OTHER: Temperature and fevers, and then any skin or other features of the examination needing to be included in the note.
LINES: Just include the lines they currently have and when they were placed

INVESTIGATIONS
– Any relevant new investigations

FASTHUGS IN BED Please (even if it’s just a little checklist at the end to remind yourself! See the link in the References for a more in-depth page on FASTHUGS)
Feeding/Fluids:
Analgesia:
Sedation:
Thromboprophylaxis:
Head up:
Ulcer prophylaxis:
Glycaemic control:
Skin:
Indwelling lines:
Nasogastric:
Bowel care:
Environment: e.g. temperature control
De-escalation: e.g. family meetings planned for tomorrow or liberating from machines such as CRRT / ventilators
Psychosocial: Including if family visiting or if social worker involved etc.

PLAN
Try and be systematic about the plan (e.g. A–>E), I also (rightly or wrongly) don’t use numbered lists, as this may be perceived to be in order of importance unless that is the order you want something, an example below;
e.g.
– Wean ventilation across to PSV today if able / tolerates same
– Send sputum sample
– If noradrenaline >20mL/h and ongoing AF, commence vasopressin as secondary agent
– If ongoing AF:
—> 1. Ensure K+ >4.0 / Mg2+ >1.0 (yes, I know that there is now less evidence for targeting higher potassium targets (extrapolated from cardiac surgery), alas… we persist)
—> 2. Further 150mg amiodarone over 30mins
—> 3. if ongoing, to commence amiodarone infusion 900mg/24 hours
– Aim to wean and cease propofol, and continue dexmedetomidine as primary agent.
– Aim fluid balance -ve 2500mL today
– If CRRT circuit clots today, not to restart unless urgent indication
– If Hb <75, please transfuse unit of red cells
– Chase sensitivities from sputum and blood cultures, and adjust antibiotics if able
– Family meeting tomorrow planned for 2pm, need to ensure surgical / medical team + family members + SW coming

ANOTHER APPROACH

If there is not much to report — such as on an afternoon ward round and it is a quick zip around, your notes may be much more brief and limited to:

PROGRESS (e.g. stable day, or, busy day — off to OT and etc etc.)
EXAMINATION (brief targeted examination)
e.g. stable vent / haemodynamics
PLAN (include plan for overnight — including thresholds to continue or cease an intervention if they have been asked for to stop any unnecessary consternation by the overnight team!

Do you have other approaches? Anything you MUST have in your ward round notes? Join the conversation, leave a Reply / Comment below!

References and Links

Articles

• Bottom Line – TIGHT-K
• Frederik H Verbrugge, Venu Menon, Potassium supplementation and the prevention of atrial fibrillation after cardiac surgery (TIGHT-K) trial, European Heart Journal. Acute Cardiovascular Care, Volume 13, Issue 9, September 2024, Pages 672–673, https://doi.org/10.1093/ehjacc/zuae102