GENERAL ICU 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.