Epic ICU Template Summer 2024

NOC SHIFT RN REPORT

History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@
@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@
MRN: @MRN@ Acct# @HARNUMID@

Admitted for
@CURRENTDIAGNOSIS@

BRIEF SYNOPSIS

CC: @CCNNOLINE@
@NAME@ is a @AGE@ @SEX@ ***

RN ASSESSMENTS/ CONCERNS/ UPDATES

  1. NEURO:
  2. CARDS:
  3. RESP:
    a. Vent: Mode
    i. @VENTSETTINGS@
    b. Secretions:
  4. GI:
    a. @DIETORD@
    i. H2O Flush:
    b. BG q _ hrs
  5. GU:
    a. Foley:
    i. Indication:
    b. UOP: adequate, yellow/clr
    c. IO:
    i. @INTAKEOUTPUTBRIEF@
  6. SKIN: Intact
  7. PAIN: CPOT 0
  8. PROPHYLAXIS:
    a. Heparin SC
    b. Protonix
  9. LABS:
    a. Lytes Repleted:
  10. GOALS:
  11. OTHER:
    a. Family

CONSULTS

@CONORDS@

ICU DRIPS & CONTINUOUS IV’s

  • Continuous Infusions:@MEDSINFUSIONS@

LINES:
– PIVs

VENT SETTINGS / ABGs

@VENTSETTINGS@

Arterial Blood Gases:

@LABRCNTIP(PHART:3,PCO2ART:3,PO2ART:3,HCO3ART:3,O2SATART,HCO3:3,O2SAT,THB,O2HB,CARBOXYHGB,METHB,HHB:3)@

Last ABG:
@LABLAST(PHART:3,PCO2ART:3,PO2ART:3,HCO3ART:3)@

@BRIEFLAB(PHART,PCO2ART,PO2ART,HGB,HBO2PER,CARBOXYHGB,HHB,HCO3ART,BEART,O2SATART,SAMPLETYPE,ROOM)@

HISTORY

@ALLERGY@
@PMH@
@PSH@
@FAMHX@
@FAMST@
@SOCHX@
@PTAMEDS@

VITALS

24 Hour Min / Max Current
@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@
@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@ 
@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@
@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@
@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@
Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@  @BMI@

LABS & RESULTS

@LABRECENT(WBC:2,HGB:2,HCT:2,PLT:2,NA:3,K:3,CL:3,CO2:3,BUN:3,CREATININE:3,GLUCOSE:3,CALCIUM:3,MG:3,PHOS:3,BILITOT:3,CONJBILI:3,AST:3,ALT:3,ALKPHOS:3,LIPASE:3,ALBUMIN:3,TOTALPROTEIN:3,APTT,LABPT,INR,CK,TROPONINT,TROPONINI,BNP,CHOL,TRIG,HDL,LDLDIRECT,TSH)@

@LABRECENT(COLORU:3,CLARITYU:3,SPECGRAVUR:3,PHUR:3,LEUKOCYTESUR:3,NITRITEU:3,PROTEINUA:3,GLUCOSEU:3,UROBILINOGEN:3,BILIRUBINUR:3,BLOODU:3,KETONESU:3,RBCUA:3,WBCUA:3,SQUAMEPIUA:3,BACTERIA:3)@
@LABRECENT(URINECX:3,Sputumcultur:3,BLOODCX:3)@
@RISRSLT2DAYSIMPRESSIONONLY@

@RESUFAST(PTT)@
@RESUFAST(INR:3,PROTIME:3)@

MEDS

Scheduled Meds:
@MEDSSCHEDULED@

PRN Meds:
.@MEDSPRN@

@DCMEDSLAST36HOURS@

INTERDISCIPLINARY TEAM PLAN
 

NURSING PLAN OF THE DAY

Maintenance Tasks
-add/maintain PIVs, check need for CVC/Foley
-monitor electrolytes
-strict I/o when ordered
-neuro checks periodically
-monitor HGB; check s/s bleeding
-ensure airway trach patency
-elevate arms, if app
-d/w attending pt status
-turned pt q2h
-fall risk observed
-wound care/prevention as necessary

Report given to oncoming RN at end of shift, who then assumed all care.

@MEMD@, BSN, CCRN
Electronic Signature
@TD@ @NOW@

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