ICU Intensivist Progress Note

Finished note

Example — generated by Notat from a sample visit

Presenting concern:
Twisted right ankle while stepping off a curb this morning. Able to bear weight with discomfort.

Assessment:
Soft-tissue ankle injury. No immediate features suggesting fracture identified in the history and examination.

Plan:
Advised rest, ice, compression, elevation, and analgesia as appropriate. Return for reassessment if unable to bear weight or symptoms worsen.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Intensivist ICU Note

Patient Identification: [Patient name, age, gender, relevant medical history, reason for ICU admission]

History of Present Illness:
[Chronological summary of events leading to ICU admission, including presenting symptoms, relevant interventions, and response to treatment]

Past Medical History:
(hyphenated list)
- [Relevant chronic conditions]
- [Previous surgeries]
- [Other significant medical history]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [IV infusions, vasopressors, sedatives, antibiotics, etc.]

Allergies:
(hyphenated list)
- [Drug allergies]
- [Other allergies]

Family History:
(hyphenated list)
- [Pertinent family medical history]

Social History:
(hyphenated list)
- [Tobacco use]
- [Alcohol use]
- [Recreational drug use]
- [Occupation]
- [Living situation]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- General: [Appearance, level of consciousness]
- HEENT: [Findings]
- Cardiovascular: [Findings]
- Respiratory: [Findings, including ventilator settings if applicable]
- Abdomen: [Findings]
- Neurological: [Findings, GCS if applicable]
- Skin: [Findings]
- Lines/Tubes/Devices: [Type, location, function]

Laboratory and Imaging:
(hyphenated list)
- [Relevant lab results with units]
- [Imaging findings]
- [Other diagnostic studies]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary diagnosis]

#) [Active problem/diagnosis as numbered item]
(hyphenated list for each problem)
- [Assessment and reasoning]
- [Investigations planned or ordered]
- [Treatment plan, including medications, procedures, supportive care]
- [Consultations requested]
- [Goals of care discussion]
- [Family communication]
- [Follow up plan]
- [Return precautions or monitoring parameters]