Pulmonary/Critical Care ICU Daily Progress Note

Date/Time of Service: [Date and time]

Provider: [Provider name, role] | Attending: [Attending name]

Unit/Bed: [Unit and bed]

Hospital Day / ICU Day / Ventilator Day: [Hospital day] / [ICU day] / [Ventilator day] (Include ventilator day only if mechanically ventilated)

Primary ICU Diagnoses: [ICU diagnoses driving current care]

Code Status: [Full code / DNR / DNI / Limited interventions] (Include date of last confirmation)

Allergies: [Allergen and reaction type]

Device Summary: [Key devices: ETT/trach, central line, arterial line, Foley, drains, RRT/ECMO as applicable]

Summary

[One-liner: age, sex, key comorbidities, ICU diagnosis, current organ support] [24-hour trajectory: improved / stable / worsened, with brief reason] (Limit to 2–4 lines total)

Interval Events / Subjective

• [Significant overnight events: hemodynamic changes, procedures, transfusions, imaging results, consultant recommendations]
• [Patient-reported symptoms] (If patient cannot participate, note why and use observational substitutes)
• [Family communication: who, when, key decisions] (If none, omit this bullet)

(If no acute events overnight, state "No acute overnight events" instead of bullets)

Objective

Vitals: [Tmax], [HR], [BP], [MAP] (Include MAP goal if on pressors), [RR], [SpO2 on device], [Net I/O 24h and cumulative if relevant]

Respiratory Support: (Include only the applicable level; omit entirely if on room air without respiratory concerns)

• Mechanically ventilated: [Airway type/size/depth], [Mode/settings: TV, RR, PEEP, FiO2], [Pressures: Ppeak, Pplat, driving pressure as available], [ABG/VBG and PF ratio], [SAT/SBT status and outcome], [Adjuncts: proning, paralysis, inhaled vasodilators if used]
• NIV: [Interface], [Settings], [FiO2], [Tolerance], [ABG response]
• HFNC: [Flow], [FiO2], [Clinical response]
• Conventional O2: [Device], [Flow], [SpO2]

Sedation/Pain/Delirium:

• [Sedation score] | Target: [Sedation target] (If target not set, use placeholder indicating gap)
• [Pain score and current regimen]
• [Delirium screen result] (If not assessable, state reason; use placeholder if not performed)
• [Current infusions with doses]

Labs/Imaging/Micro:

• [Key labs with trends and interpretation]
• [Relevant imaging findings]
• [Culture results; antimicrobials by indication with day of therapy]

Lines/Tubes/Drains: (Daily necessity review per infection prevention standards)

• [Device] — [Site] | Day [#] | [Indication] | Plan: [Continue / Remove / Replace] (Use placeholder if insertion date unknown)
• (Repeat for each device)

Assessment & Plan

(Order systems by severity; include only systems with active issues)

[Active system: Neurologic/Sedation, Pulmonary/Airway, Cardiovascular/Shock, Renal/Electrolytes, Infectious Disease, Hematology, GI/Hepatic, Endocrine/Glucose, Nutrition/Mobility/Skin, Lines/Devices]

[Assessment: problem statement with trend and key supporting data]

• [Therapeutics with targets]
• [Diagnostics and timing]
• [Monitoring parameters]
• [De-escalation/weaning criteria]
• [Contingency if worsening]

Disposition / Goals of Care

• Code status: [Status confirmed, date]
• Family update: [Who, when, decisions made]
• Anticipated course: [Key milestones and barriers]
• Transfer criteria: [Clinical criteria for step-down]

Daily Safety Review

• Pain assessed: [Yes / No] | Score: [Value]
• Sedation target: [Target] (Use placeholder if not set)
• Delirium screen: [Result / Not feasible: reason]
• SAT/SBT: [Status and outcome] (Include only if mechanically ventilated)
• VTE prophylaxis: [Agent/dose or contraindication]
• Stress ulcer prophylaxis: [Agent / Not indicated]
• Glucose control: [Regimen and target]; [Recent values]
• Nutrition: [Route]; [Goal rate or target]
• Bowel regimen: [Regimen]; Last BM: [Date]
• Line/Foley necessity: [Reviewed, plan documented above]
• Mobility: [Activity level and PT/OT involvement]
• Family engagement: [Completed / Planned]

Critical Care Time

(Include only when critical care billing applies)

The patient is critically ill with [organ system failure or threat of deterioration], requiring high-complexity management. Total critical care time this calendar date: [Total minutes] minutes. This time excludes separately billable procedures. (If family discussion time included, document medical necessity and why patient could not participate)