ICU Consult Note (Critical Care Medicine)

Date/Time of Evaluation: [Date and time of bedside evaluation]

Patient Location: [Current unit/bed]

Requesting Service/Clinician: [Service and clinician name/contact]

Consult Question: [Specific reason for ICU evaluation, including urgency] (State the physiologic concern and decision needed; avoid generic phrasing like "ICU eval.")

Clinical Summary

[One-sentence clinical snapshot: baseline comorbidities and function, precipitating problem, current supports and physiologic state]

Disposition Recommendation

• Disposition: [ICU admission / Step-down / Remain on floor / Not ICU candidate]
• Rationale: [ICU-level needs or lack thereof] (Reference specific needs: invasive ventilation, vasoactive titration, continuous monitoring, frequent therapy titration.)
• Location/Capability Requirements: [Where patient should be managed and monitoring capabilities needed]
• [If not admitting to ICU: monitoring plan and re-escalation criteria] (Reference "Call ICU / Transfer Triggers" below.)
• Re-evaluation: [Timeframe or conditions for ICU re-assessment]

Focused History

[Timeline of acute deterioration, key interventions to date, and relevant context] (Include onset, progression, fluids given, antibiotics with timing relative to cultures, respiratory support trials, vasoactive use, procedures. Add context: aspiration risk, immunosuppression, recent procedures, bleeding risk. Include only PMH that affects triage/management: cardiopulmonary disease, CKD/ESRD, cirrhosis, malignancy, immunosuppression, baseline cognitive/functional status. State history source; if unobtainable, explain why.)

Allergies & Relevant Medications

Allergies: [Allergen(s) and reaction type(s) / None known / Unknown—plan to verify with patient/family/pharmacy]

Home Medications Relevant to ICU Care: [Anticoagulants, immunosuppressants, insulin, chronic opioids/benzodiazepines, beta-blockers, home oxygen] (List only items that impact ICU decisions.)

Inpatient Therapeutics: [Active vasoactive infusions with doses/trends; sedation/analgesia; current antimicrobials and timing vs. culture collection] (Do not auto-import full medication lists.)

Physical Exam

(Focused exam supporting triage decision. Omit systems not assessed. If exam limited, state constraints.)

General/Work of Breathing: [Appearance, distress, accessory muscle use, ability to speak]

Mental Status: [Alertness, orientation, agitation/sedation level]

Airway/Ventilator Synchrony: [Synchrony, secretions, airway protection] (Include if intubated or on NIV.)

Cardiovascular: [Perfusion, capillary refill, pulses, JVP, extremity temperature]

Lungs: [Auscultation findings, asymmetry, focal vs. diffuse]

Abdomen: [Tenderness, distention, peritoneal signs] (Include if relevant to shock or bleeding.)

Extremities: [Edema, mottling, cyanosis]

Neuro: [Focal deficits, pupils, airway protection assessment if altered]

Exam Limitations: [Limitations and reasons] (Only if exam limited by active resuscitation, PPE, or patient factors.)

Objective Data

(Curate data to support acuity assessment and recommendations. Include timestamps and brief interpretation. Do not paste full panels or auto-import.)

• Vitals and Trends: [Current vitals with 6–24h ranges for unstable parameters]
• Respiratory Support: [Device, settings; if ventilated: mode, FiO2, PEEP, volumes, plateau pressure, compliance; ABG/VBG with interpretation]
• Hemodynamics: [Fluid totals, vasopressor/inotrope doses and trends, lactate trajectory, bedside echo findings if obtained]
• Renal/I&O: [Urine output trends and net fluid balance]
• Key Labs: [Abnormalities with change over time that inform decisions] (Emphasize deltas: rising creatinine, worsening acidosis, hyperkalemia, coagulopathy.)
• Imaging: [Summary with your interpretation and time obtained]

Assessment

Severity Statement: [Active organ dysfunctions and whether patient meets criteria for ICU-level monitoring/intervention]

Differential: [Prioritized differential for primary syndrome with supporting/refuting evidence] (Use probability language: "most consistent with," "concerning for," "less likely given.")

Recommendations

(Organize by problem, highest acuity first. Specify responsible team for each item in co-management scenarios.)

[Problem 1: Working diagnosis]

• Immediate actions: [First-hour priorities]
• Diagnostics: [Tests to obtain and timing]
• Therapeutics: [Medications/interventions to start, adjust, or hold]
• Monitoring: [Parameters and frequency]
• Contingency: [If X occurs, do Y]

[Problem 2: Working diagnosis]

• [Follow same structure as above]

(Add additional problems as needed.)

Call ICU / Transfer Triggers

• Respiratory: [SpO2 threshold, escalation limits, work of breathing concerns, airway protection failure]
• Hemodynamic: [MAP threshold, vasopressor initiation/escalation criteria, lactate threshold]
• Neurologic: [GCS decline threshold, new seizure, acute delirium with airway risk, new focal deficit]
• Renal/Metabolic: [Potassium threshold, refractory acidosis, anuria with complications]
• Clinical Concern: If bedside team has concern for rapid deterioration, call ICU immediately.

Goals of Care

Code Status: [Full / DNR / DNI / Other with operational meaning]

Decision-Maker: [Name, relationship, contact] (If patient lacks capacity.)

Discussion Summary: [Participants, key preferences, acceptable vs. unacceptable interventions, time-limited trial parameters] (If not yet addressed, state why and when it will be revisited.)

Communication & Follow-up

Requesting Team: [Recommendations discussed with name, time]

Family Communication: [Updated by consult team: yes/no; details if applicable]

Follow-up Plan: [ICU to follow daily / Sign off / Reassess in specified timeframe]

Escalation Contact: [Who to call for acute changes; reference triggers above]

Critical Care Time Attestation

(Include only when billing critical care codes.)

Total Critical Care Time: [Minutes] excluding separately billable procedures

Critical Illness: [Life-threatening condition(s) and management activities performed]