Patient Rounding in the SICU/CTICU

Unlike medicine or surgery rounds where a SOAP note format is often employed to present patients with the assessment and plan explored problem by problem, patient rounds in the ICU employ a systems based approach where each physiological system is presented in turn. Each system presentation begins with subjective and objective findings and then a plan for those findings is agreed upon before advancing to the next system. This approach is used in the ICU because there are often multiple problems being treated across multiple organ systems and a comprehensive approach is necessary for accurate care. For SICU/CTICU rounds at the VA each patient is presented using the following format.

NOTE: This is a comprehensive and exhaustive list – and the goal is to present those items on this list that are important for your patient. Presentations and chart notes should follow the dictum of the Bard: Brevity is the Soul of Wit. If things are normal just say “normal”. Nobody needs to hear (or read) a long list of normal vital signs or electrolytes

Patient ID: 1. Name and age of patient 2. Post-op day number and surgery 3. Any other pertinent information needed to orient the team to the patient’s treatment course

Neurological: 1. Subjective information: a. Reported pain scale (1-10) b. Sleep issues or concerns c. Numbness, dizziness, etc d. Neurological issues overnight or during the day 2. Objective information: a. Neurological exam findings (Mental status, AAO, PERRLA, strength, reflexes, etc) b. Sedation drugs and levels c. Pain drugs/treatments and levels 3. Plan: a. Changes to sedation or pain medications or levels b. Necessary diagnostic procedures (CT, MRI, LP, biopsy, etc) c. Consults

Cardiovascular: 1. Subjective information: a. Racing heart, dizziness, etc. 2. Objective information in addition to cardiovascular physical exam: a. Heart rate range last 24hrs b. Blood pressure range last 24hrs c. Palpable/doppler pulses d. Heart or vessel related medications and levels e. Lab results (cardiac enzymes, BNP, lipids, etc) f. Diagnostic study results (EKG, echo, etc) g. Relevant medications 3. Plan: a. Changes to heart or vessel medications or levels b. Necessary diagnostic procedures (EKG, echo, angiography, etc) c. Necessary treatment procedures (heart or vascular surgery) d. Consults

Respiratory: 1. Subjective information: a. SOB, cough, secretions 2. Objective information in addition to respiratory physical exam: a. Respiratory rate range last 24hrs b. 02 saturation range last 24hrs c. Chest tube output and description last 24hrs d. Current vent settings e. Lab results (blood gas, microbiology, acid/base, etc) f. Diagnostic study results (chest x-ray, CT scan, etc) g. Relevant medications 3. Plan: a. Changes to respiratory medications b. Necessary diagnostic procedures (x-ray, CT, angiograms) c. Necessary treatment procedures (bronchoscopy, CPT, etc) d. Changes to ventilator e. Evaluation of weaning parameters d. Extubation/intubation e. Consults

Gastrointestinal/Nutrition: 1. Subjective information: a. Oral intake b. Flatus or BM c. Abdominal pain 2. Objective information in addition to abdominal exam: a. PO intake last 24hrs b. Bowel output and description last 24hrs c. Abdominal drain output and description last 24hrs d. Diet type, feeding rates, TPN rates, etc e. Ostomy appearance f. Lab results (LFTs, amylase, lipase, etc) g. Diagnostic study results (x-ray, CT, etc) h. Relevant medications 3. Plan: a. Changes to GI medications b. Changes to diet or other feeding levels/rates c. Placement of NG tube or DHT d. Necessary diagnostic procedures (x-ray, CT, angiograms, endoscopy, colonoscopy, etc) e. Necessary treatment procedures (surgery, etc) f. Consults

Fluids, electrolytes, and renal: 1. Subjective information: a. Oral intake b. Urinary frequency, trouble urinating, incontinence, etc 2. Objective information in addition to GU exam: a. Total Ins and Outs with breakdown (PO, MIVF, urine output, etc) b. Maintenance IV fluids type and rate c. Electrolyte levels with comparison to previous day d. Urine description e. Drain fluid description f. Diagnostic study results (x-ray, CT, etc) g. Lab results (microbiology, UA) h. Relevant medications i. Access lines 3. Plan: a. Changes to medications b. Necessary electrolyte replacements c. Insertion or removal of Foley or drains d. Necessary diagnostic procedures (x-ray, CT, bladder scan, etc) e. Necessary treatment procedures (I/O cath, fluoro, surgery) f. Consults

Hematology: 1. Subjective information: a. Bleeding b. Fatigue, SOB 2. Objective information: a. Hematocrit current and compared to previous day b. Amount and type of blood products given c. Total blood loss d. Type of DVT prophylaxis and amount e. Lab results (HCT, HGB, PLT, INR, PTT, PT, etc) f. Diagnostic study results g. Relevant medications 3. Plan: a. Changes to medications b. Blood product transfusions c. Treatment of blood related syndromes (HIT, TRALI, etc) d. Necessary diagnostic or treatment procedures e. Consults

Infectious Disease: 1. Subjective information: a. General feeling b. Any infectious symptom c. Drainage of infectious fluids (type and amount) d. Fever 2. Objective information a. Max temperature over last 24hrs b. WBC current and compared to previous day c. Bands or other measures of infection d. Microbiology results e. Drain fluid amounts and type f. Current antibiotics including amount and length of treatment g. Diagnostic study results h. Other relevant medications 3. Plan: a. Changes to antibiotics or amounts b. Necessary labs or other diagnostic procedures (cultures, etc) c. Necessary treatment procedures (I and D, debridement, other surgerys, etc) d. Consults

Endocrine: 1. Subjective information: a. General feeling 2. Objective information in addition to physical exam: a. Blood glucose, TSH, cortisol, or other pertinent endocrine lab results b. Endocrine medications and levels (insulin, thyroid, etc) c. Other labs d. Diagnostic study results e. Other relevant medications 3. Plan: a. Changes to medications b. Necessary diagnostic procedures c. Necessary treatment procedures d. Consults