ICU Discharge Summary (Critical Care Medicine)

Author/Service: [Author name, role, service, and real-time contact (pager/phone/secure chat)]
ICU Admission: [Date-time]
ICU Discharge/Transfer: [Date-time]
Destination: [Receiving unit/service/facility]
Primary ICU Diagnosis: [Primary ICU diagnosis or physiologic indication for ICU admission] (State a diagnosis plus physiologic need rather than symptoms alone.)
Verbal Handoff: [Yes / No]; [Recipient name and role]; [Date-time] (If verbal handoff not yet completed, state planned timing and recipient.)

ICU Snapshot

• Severity at transfer: [Stable / Watcher / Unstable] (Use local equivalent if different.)
• One-liner: [Age], [key comorbidities], ICU day [#], [primary ICU problem], [major turning point or milestone]
• Active supports: (Include only those currently in use; omit categories not applicable.)
  • Respiratory: [Device/mode, key settings, O2/CO2 targets]
  • Hemodynamic: [Vasopressor/inotrope name, current dose, MAP target]
  • Renal replacement: [Modality and schedule]
• Key problems requiring close monitoring (next 24–48 hours): (Limit to 3–5 most important.)
  • [Problem 1]
  • [Problem 2]
  • [Problem 3]
• Action list with ownership and timing:
  • To do today: [Action] → [Owner/service] → [Due time]
  • To do tomorrow: [Action] → [Owner/service]
• Contingency/escalation triggers: [Explicit thresholds and actions, e.g., "If SpO2 <90% on 6L or RR >30 → call ICU at ext. XXXX"]
• Devices that change risk: [Central lines, arterial lines, drains, chest tubes, pacing wires, feeding tubes, Foley, other]
• Isolation precautions: [Type and organism/indication] (Omit if none.)
• Critical confirmations needed: [Code status / Active infusion details / Airway security / Other] (Include only items that are uncertain and require immediate reconciliation on arrival.)

Reason for ICU Admission & Key Diagnoses

[Primary reason for ICU admission as diagnosis plus physiologic need, e.g., "Septic shock from pneumonia requiring vasopressor support and mechanical ventilation"]

• [Major ICU diagnoses with dates of onset or recognition] (List only those that drove ICU-level care.)
• [Significant comorbidities that materially impacted ICU course] (Do not duplicate full PMH.)
• [Unresolved differential diagnoses affecting ongoing monitoring or plan] (Include only if relevant to current management.)

Baseline Function (Pre-ICU)

• Living situation: [Home / Facility]; [Alone / With family or caregiver]; [Support availability]
• Mobility/ADLs: [Independent / Needs assistance]; [Assistive devices used]
• Cognition/communication: [Baseline cognition]; [Language]; [Sensory impairments] (Note dementia, prior stroke, hearing/vision issues.)
• Baseline respiratory support: [None / Home O2 at ___ L/min / CPAP/BiPAP]
• Renal replacement: [None / Chronic HD or PD with schedule]
• Chronic high-risk meds: [Anticoagulation / Steroids / Opioids / Benzodiazepines] (List as applicable.)
• Source: [Patient / Family / Prior notes / Facility records] (If unknown, state: "Baseline function unknown—no collateral available.")

ICU Course

[Narrative overview in 1–2 paragraphs covering: presenting physiology, major interventions and turning points with dates, complications, and current trajectory with unresolved issues]

System-Specific Details

(Include only organ systems with significant ICU-level involvement. Omit systems that were not affected or required only routine care.)

• Respiratory: [Intubation/extubation dates, ventilator days, proning, tracheostomy, weaning status, aspiration risk, current support]
• Cardiovascular: [Shock type, vasopressor/inotrope timeline, echo findings, arrhythmias, current hemodynamic status]
• Renal: [AKI stage, CRRT/HD details, volume status, electrolyte issues, current renal function]
• Neuro: [Delirium course, sedation history, withdrawal risk, neurological events, current mental status]
• Infectious Disease: [Source(s), cultures with dates and results, antimicrobials with start dates and intended duration, response to treatment]
• Hematology: [Bleeding/thrombosis events, transfusions, VTE prophylaxis and rationale, coagulation issues]
• GI/Nutrition: [Feeding route, tolerance, aspiration precautions, GI complications, nutrition plan]
• Endocrine: [Glycemic strategy and targets, steroid indication and taper plan]

Complications: [CLABSI, VAP, CAUTI, pressure injuries with stage, drug reactions, other iatrogenic events] (Include dates and current status. Omit if none.)

Procedures

(Include only if procedures occurred during ICU stay. Omit section entirely if none.)

• [Procedure] — [Date]; [Indication]; [Complications]; [Current status (device in/out)]

Current Status at Transfer

• Most recent vitals: T [temp], HR [rate], BP [systolic/diastolic] (MAP [value]), RR [rate], SpO2 [%] on [support], Pain [score] — as of [date-time]
• Current support settings: [Respiratory support details]; [Vasopressor/inotrope and dose]; [RRT schedule] (Include only active supports.)
• Focused exam: [Mental status]; [Work of breathing]; [Perfusion]; [Lines and sites]; [Wounds/skin] (Concise, action-oriented findings.)
• Key labs/imaging requiring follow-up: [Salient abnormalities and trends]; [Pertinent imaging findings]; [Most recent ABG/VBG if on advanced respiratory support]
• I/O summary: [Net balance] (Include only if it impacts management decisions.)
• Brief interpretation: [Overall trajectory statement, e.g., "Improving respiratory failure, persistent delirium"]

Active Problems & Plan

[Problem 1] ([improving / stable / worsening])

• Assessment: [1–2 key data points driving current status]
• Plan: [Specific actions with targets and stop dates]
• Monitoring: [What to check]; [Frequency]; [Thresholds for concern]
• Contingency: If [trigger], then [action] / call [contact]
• Ownership: [Primary team / Consult service]

[Problem 2] ([improving / stable / worsening])

• Assessment: [Key data points]
• Plan: [Actions with targets]
• Monitoring: [Checks, frequency, thresholds]
• Contingency: If [trigger], then [action]
• Ownership: [Team/service]

(Add additional problems as needed, ordered by severity and time-criticality.)

Medication Transition Plan

• New or changed medications at ICU discharge:
  • [Medication] — [Dose/route/frequency]; [Indication]; [Duration or stop date]; [Monitoring required]
• Discontinued home medications: [Medication] — [Rationale for discontinuation]
• Active infusions at transfer: [Medication], [Current dose/rate], via [Line type]
• Antimicrobial plan: [Agent(s)] for [Indication]; Started [Date]; Cultures: [Results]; Day [#] of planned [#]-day course; Stop date: [Date]; [Criteria to broaden/narrow/stop]
• High-risk medications requiring attention: [Anticoagulants / Opioids / Benzodiazepines / Antiarrhythmics / Steroids / Antipsychotics / Antiseizure meds] — [Monitoring needs, taper plan, or duration]
• Home medication reconciliation status: [Complete / Partial / Uncertain] (If incomplete or uncertain, state mitigation plan and who will reconcile.)

Allergies

• [Allergen] — [Reaction type and severity]
• [Severe adverse drug reactions from this ICU stay] (Include if applicable.)

(If no known allergies, state "NKDA per chart review." If unknown, state "Allergies unknown—requires verification.")

Lines, Drains, Airways, Devices

• [Device type]; [Site and laterality]; Inserted [Date]; [Indication]; [Removal plan or criteria]

(For airways: include type, size, cuff status, speaking valve if applicable. For drains: include output characteristics and removal criteria. Use placeholder with "[Date unknown]" or "[Indication unclear—needs confirmation]" if information is missing.)

Code Status & Goals of Care

• Current code status: [Full code / DNR / DNR-DNI / Other] — Effective [Date]
• Surrogate decision-maker: [Name], [Relationship], [Contact phone]
• Goals-of-care summary: [Key discussions, decisions, time-limited trials, palliative involvement with dates]

(If code status is not documented, state: "Code status not documented—must clarify on arrival to floor.")

Consultations & Follow-up Responsibilities

• [Consulting service]: [Active recommendations]; [Pending question or decision]; [Next step]; [Owner of follow-up]

(List only active consults with ongoing responsibilities.)

Pending Results

• [Test pending]; Sent [Date]; Expected [Timeframe]; Owner: [Team/person]; Action if abnormal: [Plan]

(Include pending cultures, pathology, send-out labs, and imaging interpretations. If none, state: "No known pending critical results at time of transfer.")

Functional & Cognitive Status

• Mobility: Baseline: [Status] → Current: [Status] → Plan: [PT/OT recommendations, fall risk level, equipment needs]
• Cognition: Delirium during ICU: [Yes / No]; Current: [Orientation, attention, agitation risk]; Communication barriers: [Language, sensory, cognitive]
• Swallowing: [Diet texture / NPO / Tube feeds]; SLP recommendations: [Details]
• PICS risk: [High-risk features present]; [Planned monitoring or referrals]

(If any domain not assessed, state "Not assessed" with reason rather than omitting or implying normal.)

Disposition & Escalation Criteria

• Destination: [Ward / Step-down / Transfer facility] — [Rationale for level of care]
• Monitoring requirements: [Telemetry / Neuro checks q___ / Vitals q___ / Glucose checks q___ / Other]
• Escalation triggers: If [RR >X, SpO2 <X%, MAP <X, UOP <X, mental status change, other] → [Call ICU / Activate RRT / Notify attending] at [Contact]