ICU documentation templates??

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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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What EMR do you guys use?

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Please experienced ICU nurses give us new grads some information on how to document. Templates are welcome. I need help, with documenting too.

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Specializes in ED, ICU, Education.

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!

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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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