ICU documentation templates??

  1. 0
    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!!!
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  3. 4 Comments so far...

  4. 0
    What EMR do you guys use?
  5. 0
    Please experienced ICU nurses give us new grads some information on how to document. Templates are welcome. I need help, with documenting too.
  6. 0
    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
    Hx
    Neuro
    Pulmonary
    Mode Tv Peep F1o2
    Cardiac
    GI
    LBM
    GU
    Skin/Wound
    IVs
    Fluids/Drips
    Things to do
    GI
    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!
  7. 0
    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
    Precautions
    Neuro
    CV
    Resp
    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.


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