How to present a patient on rounds

Sample ICU Presentation Format: (A thorough, concise note with a focus on the key issues with the patient gives us all the info we need so we don't have to interrupt your presentation with questions). A good template is the old hand-written ICU notes.

ONE LINER: 52yoM s/p GSW to abdomen hospital day 39 s/p SBR, nephrectomy and multiple abdominal washouts, now trached and PEG-ed POD # __

S: Major overnight events (ex: failed SBT 2/2 tachypnea to 45 or went to OR for washout)

O: Vital signs - give ranges on the ICU patients with an emphasis on pertinant details like drain outputs on surgical patients and ICP on head trauma pts

   Ex: Tmax 102.5 (only >101.5 is a fever), HR 100-120s, BP 120-150/40-60s, on vent AC 500/14/40%/PEEP 5 with most recent gas 7.4/40/125/-5/97%

   MAP on pts on pressors or on spinal perfusion protocol, UOP 50-100cc/h

   Drain output, CT output

Physical Exam: (be sure to include all incisions (CHANGE ALL DRESSIGNS EVERY DAY), quality of drain output, whether CT has an air leak)

Medications: Be brief, don't have to include doses.  Emphasize drips, IVF, and antibiotics.  When you list antibiotic be specific about what you're treating and duration, (ex: day 4 of 7 of bactrim for catheter related E. coli UTI )

Devices: Foley, central line (note when placed)

Labs: Emphasis on pertinent positives.  Give previous value for any abnormal values (ex: Hb trending downward)

Cultures - give new cultures and whatever the last negative blood culture date is (if needed)

A/P: (by system)

1.        Neuro: pain control, sedation, neurologic injuries, daily sedation holiday

2.        if consulting neuro ask about positioning (log roll, reverse trendeleburg to eat, need for brace, etc)

3.        CV: ex: hypotensive and tachycardic, likely septic shock, will continue crystalloid boluses for MAP >60 and levo if that fails.  "Continue to monitor" is NOT a complete plan.  Outline what you would do if the status changes.

4.        Pulm: vent settings, pulm status (ex: pna, ARDS, PTX, CT) minimal ventilatory settings, good pulmonary mechanics and oxygenating well, plan for another SBT today.  CT to suction and no PTX or air leak, so will put to water seal today and check another CXR.

5.        GI: Tube feeds + glutamine at goal via DHT, so will half TPN today, then off tomorrow.

6.        GU: Good renal function, adequate UOP and CR normal.  Continue foley while sedated.

7.        ID: On bactrim day 4/7 for E. Coli UTI.. All blood cultures negative so far.  Will pan culture if spikes >101.5.

8.        FEN: Plan to continue IVF while resuscitating for sepsis, on LR at 150.  Replete Mg to 2, Phos to 3 and K to 4 per elecrolyte repletion careset.  Nutrition labs every Mon and Thurs.

9.        Skin: Skin exam every mon and thurs - duoderm to stage II sacral decub

10.     Dispo: Seen by PT and recommend LTAC, SW working on placement options.  Rehab consult pending.

Obs and floor presentations should also be given in SOAP format, but not as much detail is required. 

Mention one liner, vital signs (especially abnormal values), pertinent physical findings, pertinent labs, then plan should include pain control (oral if on diet), wound care, prophylaxis, and disposition (consults, OR, PT recs, SW issues, plan for discharge and follow-up).

Thanks, Marie Ziesat, MD.