General Considerations


  • Be Organized
  • Be Involved
  • Be Thorough
  • Be Efficient
  • Do Not Lie

Clinical Documentation

  • Organ based, particularly on admission, also with very complicated patients
  • Problem based, particularly when patients have been in the hospital for > 5 days

Daily assessment of:

  • Problem List
  • Goals of care
  • Sedation
  • Ventilator Settings, ETT size, duration of MV, Peak/Plateau Pressures, VAP prophylaxis
  • Lines, CLABSI prophylaxis
  • Tubes, CAUTI prophylaxis
  • GI and DVT prophylaxis
  • FEN (including volume status)
  • Duration of abx
  • Transfusion totals
  • Of note, when code status has been established, unless there is a change in clinical condition that would lend the physician to believe resuscitation would be futile, do not readdress. This is particularly important when patients are DNR/DNI, it is extremely confusing to have more than one team discuss this over and over.