Critical Care Note (Time-Based)

Date of Service: [Date]

Location: [ICU / ED / stepdown / other]

Patient: [Patient identifier]

Author: [Clinician name and credentials]

Critical Illness Statement

[Critical illness statement including affected organ system(s), objective anchors, imminent risk without intervention, precipitating event or trend, and high-intensity management being provided] (Name specific physiologic threat(s) and organ failure(s). Anchor with key objective data. If diagnosis is uncertain, document the syndrome and differential guiding treatment. Avoid vague terms; specify why the situation is time-sensitive.)

Clinical Summary

[Brief narrative of presentation or interval events and treatments with response] (For new or worsening issues, describe what changed and when, therapies given, and response. For stable follow-up, summarize interval events.)

Vitals/Monitoring: [Key parameters and trends relevant to acuity]

Exam: [Pertinent positives and negatives] (Note if limited by sedation, paralysis, or device constraints.)

Organ Support: [Ventilator settings, vasoactive infusions with doses, renal replacement therapy, key lines and devices] (List current supports and notable changes.)

Data: [Pertinent labs, imaging, microbiology, and pending results influencing decisions] (Summarize concisely; do not paste result dumps.)

Assessment & Plan

(Order problems from most life-threatening to least.)

[Problem 1]: [Diagnosis or physiologic syndrome] [worsening / improving / stable / unstable]

• Key data: [1–3 objective anchors]
• Assessment: [Brief clinical reasoning and differential if uncertain and management-altering]
• Interventions: [Specific actions with doses, targets, and titration parameters]
• Monitoring/Targets: [Physiologic goals and thresholds prompting escalation]
• Response: [Observed response or persistent instability] (Only if applicable today.)
• Coordination: [Consults or goals-of-care discussions that changed management] (Only if applicable.)

[Problem 2]: [Diagnosis or physiologic syndrome] [worsening / improving / stable / unstable]

• Key data: [Objective anchors]
• Assessment: [Brief reasoning]
• Interventions: [Specific actions]
• Monitoring/Targets: [Goals and contingency triggers]

(Add additional problems as needed. Include Response and Coordination lines only when applicable.)

Procedures: [Procedure name(s) with indication; reference separate procedure note] (Only if performed today.)

Critical Care Time

Total Critical Care Time: [Number] minutes on [Date]

[Brief description of qualifying critical care activities such as titration of organ support, interpretation of complex data, high-complexity decision-making, and care coordination]

Excluded Procedure Time: [List each separately billable procedure and excluded time] (Only include if procedures were performed.)

[Start–stop times or non-contiguous segments] (Optional; recommended for audit transparency.)

(Do not finalize until critical care time is determined. Document only time personally spent by billing provider.)