ICU Daily Progress Note (Critical Care Medicine)

Date/Time: [Date and time of note]

Author: [Author name, credentials, role, service]

Location: [ICU name / Bed]

Hospital Day / ICU Day / Vent Day: [Hospital day #] / [ICU day #] / [Vent day # if mechanically ventilated]

Primary Diagnosis: [Primary critical illness or reason for ICU admission]

Code Status: [Full code / DNR / DNI / Other] — Decision-maker: [Name and relationship] (If unknown: [Code status unknown — verify and update orders today])

Isolation: [None / Contact / Droplet / Airborne / Other] (Only include if applicable.)

ICU Summary

[1–2 sentence summary of current critical illness, major organ failures/syndromes, and active life support: airway type, ventilation mode, vasopressors/inotropes, RRT, mechanical circulatory support.] (Keep concise; include only what is active today.)

Interval Events (Last 24h)

[Brief narrative of clinical trajectory: improved / stable / worsened.] [Significant events: hemodynamic changes, respiratory escalation/weaning, arrhythmias, fever, procedures, neurologic changes, major medication changes, adopted consult recommendations, family or goals-of-care discussions.] (If handoff incomplete: [Information limited by [source]; will clarify with [team/person] today].)

Objective

(Summarize decision-relevant data with 24h ranges and most recent values. Avoid exhaustive data dumps. Reference timestamps for imported data.)

• Vitals (24h range; most recent):
  • Temp: [Range] ([Most recent] at [time])
  • HR: [Range] ([Most recent] at [time])
  • BP: [Range] ([Most recent] at [time]) [A-line / NIBP]
  • MAP: [Range] ([Most recent] at [time])
  • RR: [Range] ([Most recent] at [time])
  • SpO2: [Range] ([Most recent] at [time]) on [O2 device/settings]
• Respiratory Support:
  • Airway: [ETT / Tracheostomy / Native] (Size/depth if applicable)
  • Mode: [VC-AC / PC-AC / PRVC / PSV / SIMV / APRV / BiPAP / HFNC / NC / Room air]
  • Settings: FiO2 [%], PEEP [cm H2O], VT [mL or mL/kg PBW], RR [set], PS [if applicable]
  • ABG/VBG ([time]): pH [value], PaCO2 [value], PaO2 [value], HCO3 [value], Lactate [value] (Include if clinically relevant.)
  • Lung mechanics: Pplat [value], Driving pressure [value], Compliance [value] (If available and relevant.)
• Intake/Output (24h):
  • Intake: [mL] / Output: [mL] / Net: [mL]
  • Urine output: [mL/24h] ([mL/kg/h])
  • Weight: [Today's weight] (Trend: [up / down / stable] vs [reference]) (Include when fluid status is active.)
• Active Infusions:
  • Vasopressors/Inotropes: [Agent, dose/rate]
  • Sedation/Analgesia: [Agents, dose/rate]
  • Insulin: [Type, rate, target range]
  • Anticoagulation: [Agent, rate, goal levels]
  • CRRT: [Modality, dose, anticoagulation]
• Physical Exam:
  • General: [Appearance, comfort, devices present]
  • Neuro/Sedation: [Arousal, orientation, focal findings, RASS, CAM-ICU]
  • Cardiovascular: [Rhythm, perfusion, edema]
  • Pulmonary: [Work of breathing, breath sounds, secretions]
  • Abdomen: [Distension, tenderness, bowel sounds, feeding tube]
  • Skin/Wounds: [Pertinent findings only]
• Labs (with trends):
  • CBC: WBC [trend], Hgb [value], Plt [trend]
  • Metabolic: Na/K/Cl/HCO3 [values], BUN/Cr [trend], Glucose [range]
  • Hepatic: AST/ALT, Alk Phos, Bili, Albumin (Include if relevant.)
  • Lactate: [Values with times and trajectory]
  • Other: [Decision-relevant labs: troponin, BNP, coags, drug levels as indicated]
• Microbiology:
  • [Source] ([date collected]): [Result or Pending] (Include organism and susceptibilities if known.)
  • Rapid tests: [PCR/Ag results with date]
• Imaging/Diagnostics:
  • [Study] ([date]): [Concise interpretation and clinical implication]

Assessment & Plan

(Address only active ICU problems. Omit or compress to one line systems without active issues. Make plans actionable with specific targets, doses, thresholds, durations, and de-escalation criteria. Reconcile each system with current data; do not copy forward without updating.)

Neurologic / Sedation / Delirium

[Diagnosis or physiologic state]

• Goals: [Arousal target: RASS], [Pain target: CPOT/NRS], [Daily awakening plan]
• Plan: [Analgesia and sedation regimen with doses], [Delirium prevention/treatment], [Neuromonitoring], [Consults/imaging if needed]
• De-escalation: [Criteria to reduce/stop sedation or remove monitors]

(If inactive: [No acute neurologic issues — maintain sedation targets; daily SAT if ventilated.])

Respiratory / Ventilation

[Primary respiratory problem; oxygenation/ventilation status]

• Goals: [SpO2 target], [PaO2/PaCO2 targets], [Lung-protective targets if ARDS: VT mL/kg PBW, Pplat, driving pressure]
• Plan: [Vent strategy and settings], [Recruitment/proning if indicated], [SBT readiness and plan], [Weaning steps]
• De-escalation: [Criteria for extubation or step-down to NIV/HFNC]

Cardiovascular / Hemodynamics

[Shock type or hemodynamic status; volume status and perfusion]

• Goals: [MAP target], [HR/rhythm goals], [Perfusion markers: lactate, UOP]
• Plan: [Vasopressor/inotrope plan with doses and titration parameters], [Fluid or diuresis strategy], [Monitoring]
• De-escalation: [Criteria to wean pressors or remove lines]

Renal / Fluids / Electrolytes

[AKI/CKD status; UOP; RRT if applicable]

• Goals: [UOP target], [Fluid balance goal], [Electrolyte targets]
• Plan: [Diuresis vs fluid strategy], [Electrolyte repletion], [RRT prescription if applicable], [Dose adjustments]
• De-escalation: [Criteria to stop RRT or diuretics]

Infectious Disease

[Suspected/confirmed source; severity; source control status]

• Antibiotics: [Regimen with doses; day # of planned # days; de-escalation triggers]
• Micro: [Pending cultures; susceptibility follow-up]
• Source control: [Procedures planned/completed; reassessment timeline]

GI / Nutrition

[Feeding route and tolerance; GI issues]

• Nutrition: [Enteral / Parenteral], [Formula], [Goal rate], [Advancement plan]
• Bowel regimen: [Agents]; Last BM: [date]
• Stress ulcer prophylaxis: [Agent] — [Indication] — Stop: [date/criteria]

Hematology

[Anemia/coagulopathy/bleeding risk]

• Transfusion: [Thresholds and strategy]
• VTE prophylaxis: [Pharmacologic / Mechanical / Contraindicated: reason]
• Anticoagulation: [Indication, agent, monitoring targets, duration] (If applicable.)

Endocrine / Glycemic Control

[Glycemic status or other endocrine issues]

• Target: [Glucose range]
• Plan: [Insulin regimen], [Monitoring frequency]

(Additional systems if active: Dermatology/Wounds, Toxicology, Transplant — use same format: diagnosis, goals, plan, de-escalation.)

Lines & Devices

(Daily necessity review required. Include insertion date, indication, and removal criteria for each.)

• Airway: [ETT/Trach, size] — Day [#] — [Indication] — Remove when: [criteria]
• Central line: [Site, lumens] — Day [#] — [Indication] — Remove when: [criteria]
• Arterial line: [Site] — Day [#] — [Indication] — Remove when: [criteria]
• Foley: Day [#] — [Indication] — Remove when: [criteria]
• Drains/Tubes: [Type, site] — Day [#] — Output: [volume/character] — Remove when: [criteria]
• RRT/ECMO access: [Site] — Day [#] — [Indication] — Remove when: [criteria]

Safety Bundle

• SAT: [Ready / Not ready / N/A] — Performed: [Yes / No / Deferred: reason]
• SBT: [Ready / Not ready / N/A] — Result: [Passed / Failed / Not attempted]
• Sedation/Delirium: Target RASS [value]; CAM-ICU: [Positive / Negative]
• VAP prevention: HOB ≥30°: [Yes / No]; Oral care: [Yes / No]; Cuff pressure: [Adequate / Not checked]
• Line/Foley necessity: Reviewed: [Yes / No]; Removal plan: [action/date or N/A]
• VTE prophylaxis: [Pharmacologic / Mechanical / Contraindicated: reason]
• Stress ulcer prophylaxis: [Indicated / Not indicated]; [Agent if applicable]
• Glycemic control: Target: [range]; Protocol: [Yes / No]
• Mobility: [ICU mobility level / PT-OT status / Activity plan]

Disposition & Tasks

• Disposition: [Continue ICU / Stepdown-ready / Floor-ready] — Barriers: [list if applicable]
• Family communication: [Updated / Pending] with [contact] on [date] (If pending: [Plan to update by time])
• Consults: [Active/pending consults with specific questions]
• To-Do Today:
  • [Procedures and timing]
  • [Labs to obtain]
  • [Lines/devices to remove if criteria met]
  • [Therapy evaluations: PT/OT/SLP/RT]
  • [Medication changes to implement]

(If any information is unavailable, include placeholder noting the limitation and action to resolve. Each system must be actively reconciled with current data at time of documentation.)