Trauma ICU Progress Note (Systems-Based)

Date/Time: [Date and time of note]

Author: [Author and supervising clinician if applicable]

Location: [ICU unit and bed]

Hospital Day / ICU Day / Post-Injury Day / Post-Op Day: [As applicable]

Code Status: [full code / DNR / DNI / DNR-DNI / other] (Include decision-maker if not the patient)

Isolation: [none / contact / droplet / airborne / neutropenic / other] (Only include if relevant to care or infection control)

Patient Summary

[1–2 line orientation statement: age, sex, mechanism of injury, key injuries, major operations/procedures to date, current clinical state including ventilator status, vasopressor status, and key devices in place] (Keep concise; include only facts that frame today's ICU priorities.)

Injury Inventory

• [Confirmed injuries by region with brief descriptors]
• [Major operations/procedures with dates]
• [Active precautions: spine / weight-bearing / pelvic as applicable]
• [High-risk devices in place: external fixator / EVD / wound VAC / other]

Interval History

[Overnight or last-shift events: hemodynamic changes, ventilator adjustments, fevers, transfusions, procedures performed, agitation/delirium episodes, new imaging obtained, response to key interventions] (Include patient-reported symptoms only if they materially affect management. If no acute events occurred, explicitly state "No acute events overnight." Do not copy forward prior days without confirming accuracy.)

Objective

(Include only clinician-observed or measured data from the current shift/day. Show trend directionality where meaningful. If expected data are unavailable, document as "not obtained" or "not charted" with reason and plan to obtain if clinically needed.)

Vitals: [Temperature, HR and rhythm, BP/MAP range and current value, RR, SpO2, current weight if relevant] (Include fever curve trend if relevant.)

Respiratory Support: [Airway type and security; mode; set RR; Vt with mL/kg PBW if lung-protective; PEEP; FiO2; relevant ABG with brief interpretation; weaning readiness and SBT candidacy] (For non-intubated patients: device, flow or FiO2, and work of breathing assessment.)

Hemodynamics: [MAP goal if specified; vasopressor/inotrope agents with current dose and yesterday → today trend; lactate trend if in resuscitation; perfusion markers]

I/O and Drains (last 24h): [Total intake; total output; net balance; urine output in mL/kg/hr if meaningful; significant drain outputs that influence decisions]

Lines/Tubes:

• [Device type and location; insertion date; indication status; site concerns if any]
• [Foley catheter: necessity reviewed; removal/continuation plan]
• [CVC: necessity reviewed; removal/continuation plan]

Labs/Imaging/Micro:

• [Key laboratory results with trends that influence today's plan]
• [New imaging: 1–2 line interpretation tied to management] (Do not paste full radiology report.)
• [Microbiology: source, collection date, organism/result or pending status, relevance to antibiotic decisions]

Physical Exam

(Brief systems-based findings documenting what matters today. Avoid lengthy normal templates.)

• General/Sedation: [Appearance; level of distress; sedation/analgesia state; restraints if used]
• Neuro: [GCS if applicable; pupils; focal deficits; ICP/CPP if monitored] (Explicitly state exam limitations due to sedation or paralysis.)
• Respiratory: [Vent synchrony or work of breathing; breath sounds; secretion burden]
• Cardiovascular: [Heart sounds; rhythm; perfusion; edema]
• Abdomen: [Distension; tenderness; wounds; ostomies; drains]
• Skin: [Pressure areas; dressings; rashes or lesions]
• Extremities/MSK: [Splints/fixators; neurovascular status; compartment exam if indicated; mobility restrictions]

Assessment & Plan

(Organize by system in consistent daily order. For each active system: state problem(s), trajectory, specific goals/targets, today's plan, and contingency triggers. Omit systems without active issues unless policy requires documentation.)

Neuro

[Primary neurologic diagnoses/problems] — [improving / stable / worsening]

• Pain: [Analgesic strategy; multimodal plan]
• Sedation: [Target RASS; titration/weaning plan]
• Delirium: [Screening status; prevention measures]
• TBI/SCI care: [ICP/CPP goals; MAP targets; seizure prophylaxis; osmolar therapy] (Include only if applicable.)
• Restraints: [Indication; reassessment plan] (Include only if used.)

Respiratory

[Primary respiratory diagnoses] — [improving / stable / worsening]

• Ventilator strategy: [Lung-protective goals if applicable; current settings and targets]
• SAT/SBT: [Plan and timing; extubation readiness; barriers if present]
• Chest tubes: [Status; air leak management] (Include only if applicable.)
• Pulmonary hygiene: [Secretion management; recruitment; mobility]

Cardiovascular

[Shock category if present; arrhythmias] — [improving / stable / worsening]

• Pressors/Inotropes: [Agents with rationale; weaning plan; MAP goal]
• Transfusion targets: [Thresholds if actively bleeding or ischemic]

GI / Nutrition

[Nutrition status and abdominal issues] — [improving / stable / worsening]

• Nutrition: [Route; caloric/protein goal; aspiration risk considerations]
• Stress ulcer prophylaxis: [Agent and indication / not indicated with rationale]
• Bowel regimen: [Agents; last BM date]
• Abdominal injuries: [Solid organ grades; anastomoses; open abdomen status; drain outputs] (Include only if applicable.)

GU / Renal / Fluids

[Renal function and fluid status] — [improving / stable / worsening]

• Renal status: [AKI stage or CKD; creatinine trend]
• Electrolytes: [Significant derangements and correction plan]
• Fluids: [resuscitation / euvolemia / deresuscitation]; [daily net goal]
• RRT: [Modality and targets] (Include only if applicable.)
• Foley: [Necessity; removal or continuation plan]

Heme / Coagulation

[Hematologic status and bleeding/thrombotic risks] — [improving / stable / worsening]

• Trends: [Hemoglobin, platelets, coagulation indices]
• VTE prophylaxis: [Type; contraindications or hold parameters if applicable]
• Therapeutic anticoagulation: [Indication; monitoring plan] (Include only if applicable.)
• Transfusion thresholds: [Targets if actively managed]

Infectious Disease

[Suspected/confirmed infection sources] — [improving / stable / worsening]

• Culture status: [Sources; dates; results or pending]
• Antibiotics: [Agent(s); day number; indication; de-escalation trigger or anticipated stop date]
• Source control: [Planned procedures or interventions]
• Isolation: [Status and precautions] (Include only if applicable.)

Skin / Wounds / MSK

[Wound and musculoskeletal status] — [improving / stable / worsening]

• Pressure injury prevention: [Turning schedule; support surfaces]
• Incisions/Wounds: [Status; dressing plans; wound VAC if applicable]
• Orthopedic injuries: [Compartment checks; neurovascular findings; fixation plans; mobility restrictions] (Include only if applicable.)

Daily ICU Goals

(Document status for each element. Provide brief rationale when deferred or contraindicated.)

• Pain/Sedation: [At target / above target / below target]; [minimization plan]
• Delirium screening: [completed / not completed]; [CAM-ICU result if done]
• SAT/SBT: [candidate / not candidate with reason]; [result if performed]
• HOB elevation: [at goal / not at goal with rationale]
• VTE prophylaxis: [type / held with reason and restart plan]
• Stress ulcer prophylaxis: [indicated / not indicated with rationale]
• Glucose control: [Target range; current insulin strategy]
• Nutrition: [at goal / advancing / NPO with reason]
• Bowel regimen: [Agents; last BM date]
• Foley necessity: [remove today / continue with indication]
• CVC necessity: [remove today / continue with indication]
• Antibiotic stewardship: [Culture review status; de-escalation or stop plan]
• Mobility/Rehab: [Current level; next steps]
• Family/GOC: [completed / planned with timing / not indicated today]

Disposition & Next 24 Hours

• Expected course: [remain ICU / consider stepdown] with rationale
• Anticipated procedures: [Procedures and timing]
• Consult follow-ups: [Services and questions to address]
• Escalation triggers: [If-then contingencies for deterioration]