ICU documentation templates??

  1. I am a recent graduate who just got my first job working in the ICU. We have online documentation and have to enter vitals q hr and do assessments q4 hrs. I was wondering if anyone had any good templates they go by for their documention? also if anyone had any templates or tips for report?!

    Any tips/advice is WELCOMED!!!
  2. 4 Comments

  3. by   netglow
    What EMR do you guys use?
  4. by   Mr I Care
    Please experienced ICU nurses give us new grads some information on how to document. Templates are welcome. I need help, with documenting too.
  5. by   resumecpr
    My template begins with the patient sticker (top left) then from left to right, allergies, code status, age, attending MDs, weight, family names and contact #'s, then the password for giving info.
    Then Dx
    Mode Tv Peep F1o2
    Things to do
    Each heading has a few lines after for notes pertaining to the system

    The right column goes by hour with about 1/4 inch of space to write what need to be done at that time. Included in this space is UOP and CT (chest tube)
    Every 4th hour there is a space for temp and meal % eaten.

    Hope this helps! Welcome to nursing!
  6. by   AaronInTheBay
    Hi there,
    I just started as a new graduate recently at a busy trauma center ICU.
    We also use an online system to chart vital signs, I&O, assessments and nursing care. The program is called VisICU/ CareWatch; this is used in conjunction with the eICU.

    I will try to upload my template later, but it is quite similar to the one shown above:
    Patient sticker, diagnosis, allergies, code
    History, history of present hospitalization
    IV Fluids, Drips, IVs
    Diet, BG, activity, weight
    GI/GU, LBM
    Skin, wound, drain
    Psych social, family
    Bottom rows contain time blocks

    My template is set up in SBAR format; it works well giving report from as well as using when calling the MD.