This is a TICU progress note TEMPLATE. It is important separate injuries by system and then by problem to make sure they are all being addressed appropriately. This template will guide your presentation and make things flow smoothly.
This is a <++> year old <++> who presents on <++> as a <++> after <++>.
Patient has a history of <++>.
Trauma bay course remarkable for <++>.
Injuries (by system):
Head:
Spine:
Chest:
Intraperitoneal:
Retroperitoneal:
MSK:
Consults:
Neuro
GCS:
# Sedation
gtt:
sch:
prns:
# Pain
gtt:
sch:
prns:
Cardiovascular
MAP:
HR:
Pressors:
Trops:
EKG:
ECHO:
Respiratory
Vent settings:
ABG:
CXR:
GI/Nutrition
Diet:
NGT/OGT:
BM:
Bowel reg:
Renal
UOP:
Foley:
BMP:
Mg/Ph:
IVF:
Free water flushes:
Fluid Status:
Diuresis:
Hematology
Hgb:
Platelets:
Infectious
Temperature:
WBC:
Cx | Blood | Sputum | Wound | |||
---|---|---|---|---|---|---|
date |
Endocrine
Blood glucose range last 24 hrs:
Insulin:
Insulin requirements in last 24 hrs:
POC BG Schedule:
MSK
PT/OT
PPx
DVT:
GI:
Access
Disposition
TICU