673 uses
Intensive Care Unit Progress Note
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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™
symptoms
Injury: Right ankle pain after twisting injury this morning
history of present illness
Function: Able to bear weight with discomfort
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
assessment
Working diagnosis: Soft-tissue ankle injury
plan
Advice: Rest, ice, compression, elevation, and return precautions
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
denials of symptoms
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
Template
ICU Progress Note Patient Identification: [Patient name, age, gender, reason for ICU admission, relevant medical history] Subjective: (hyphenated list) - [Brief summary of overnight events or interval history] - [Patient-reported symptoms if applicable] - [Family concerns or updates] Objective: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [Ventilator settings and respiratory support] (e.g., Mode, FiO2, PEEP, Rate) - [Lines, tubes, drains present] (e.g., Central line, Foley catheter, Chest tube) - [Physical exam findings] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant) - [Laboratory results] (Include most recent and relevant labs with units) - [Imaging and other investigations] (Include completed results only) Assessment: (hyphenated list) - [Primary diagnosis and current status] - [Secondary diagnoses or active problems] - [Response to treatment] - [Complications or new issues] Plan: (hyphenated list) - [Hemodynamic management] - [Respiratory management] - [Renal management] - [Infection control/antibiotics] - [Nutrition plan] - [Sedation/analgesia] - [DVT prophylaxis] - [GI prophylaxis] - [Consultations/referrals] - [Planned investigations] - [Family communication] - [Goals for next 24 hours] - [Discharge planning or transfer considerations]
Shared by
LM
Dr. Lucas Meyer
Emergency Physician, Germany
How it works in Notat
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