This is my latest template for EPIC in the ICU. Feel free to disseminate to other healthcare professionals.
END OF SHIFT RN REPORT
ATT: @ATTPROV@
PCP: @PCP@
@NAME@ @AGE@(@BDAY@)
@DEPTNME@
@RRHLOS@
MRN: @MRN@
ED Arrival Time
@EDARRIVALTIME@
Current Inpt Attending:
@ATTPHY@
@CODESTATUS@
SYNOPSIS
Admitted for
@PROBLEM@
ER Presentation
@VISITINFOCC@
@VISITINFOHPI@
ICU Presentation
@NAME@ is a @AGE@ @SEX@ ***
•
@NOTESUMMARIES(1&0&0)@
@PROB@
ASSESSMENTS/UPDATES/CONCERNS
NEURO
• Behavioral description:
o Notable RASS increases:
? Sedation management:
o Notable CPOT increases:
? Pain med management:
• Temperature:
• Pupils: PERRL
• Weakness/Exceptions/Aberrations:
• FC/MAE/ROM?:
• Sedation Vacation today?
CARDS
• Majority rhythm:
• Pertinent Meds
• MAP Goal
• PRNs
• Blood Thinners?
RESP
• O2 supplement:
• CPAP today?
o Patient tolerance/duration:
• Vent Settings:
• Daily ABGs?
• Secretions:
• Home equipment?
Blood Gases:
Arterial Blood Gases:
@LABBRIEF(FIO2,PHA,PCO2A,PO2A,HCO3ACTA,BEB)@
GI
• @DIETORDERSNOQUESTIONS@
• @DIETFNSORD@
• H2O Flushes for Na?
• Route:
o Swallows pills ok?
• Appetite?
• BG Checks?:
• Last BM:
GU
• Foley y/n?
• Indication:
• Urine appearance:
• 24 Hour I/O @IOBRIEF@
SKIN
• Intact?
• Wounds:
• New/old?
AMBULATION
• Mobility:
PAIN
• CPOT scale
• PO pain management? :no
LABS
• Lytes repleted:
• Serial collection?:
• Daily CBC/CMP:
• Criticals:
• Microbio:
PROPHYLAXIS
• Heparin subcutaneous
• Protonix
• SCD
RESTRAINTS
• Y/N:
• Reason:
• If continued, orders updated?
MAIN PROBLEM TODAY
1.
PT GOALS
1.
PROVIDER PLANS
*see provider notes for more
OTHER INTERVENTIONS
- OTHER ISSUES
• Family matters:
PRECAUTIONS
• Isolation: standard
• Inpatient: fall
CONSULTANTS
- @CONORDS@
REMAINING TASKS ENDORSED TO NEXT RN:
- DRIPS & VENT
@CONTINUOUS@
ICU DRIPS & CONTINUOUS IV’s
LINES:
PIVs
•
CENTRAL
•
VENT SETTINGS / ABGs
Vent Settings:
@IPVITALS(2:6500)@
@IPVITALS(2:6501)@
@IPVITALS(2:6503)@
@IPVITALS(2:1000173)@
@IPVITALS(2:6506)@
@IPVITALS(2:6516)@
VITALS
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
{SNP Linked Labs:23727}
@LABBRIEF(NA,CL,BUN,K,CO2,CREATININE,GLUCOSE)@
@LABBRIEF(WBC,HGB,HCT,PLATELETS)@
@LABBRIEF(PT,INR,APTT)@
@LABBRIEF(CA,MG,PHOS)@
@LABBRIEF(ALB)@
@LABBRIEF(LACTICACID,LACTWBVENPC,TROPONINI,TROPONINHS)@
@LABSPENDING@
IMAGING
@IMAGERESULTS48H@
ORDERS
MEDS & ACTIVE ORDERS
See MAR
@ACTIVEORD@
@DCMED@
NURSING PLAN
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
-skin checks q shift w/RN 4 eyes verification
Report given to oncoming NOC ICU RN, , at end of shift, who then assumed all care.
*nurse*, BSN, RN, CCRN
Electronic Signature
@TD@ @NOW@