Intensive Care Unit Progress Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

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]