Patient: Name, age, brief reason for admission
Hospital Day: X
ICU Day: X
Vent/Pressors: List settings + drips

Interval Events (past 24 hours)

• Hemodynamics

• Ventilator changes

• Labs/ABGs

• Imaging

• New drips, new antibiotics

• Procedures

• Response to interventions

Vitals Summary

• Tmax, MAP range

• HR trends

• SpO₂ range

• UOP per hour

• I/Os summary (net +/–)

Ventilator Data (if applicable)

• Mode:

• FiO₂:

• PEEP:

• TV:

• Peak / Plateau pressure:

• ABG: pH / pCO₂ / pO₂ / HCO₃

Physical Exam Focused

• Neuro: RASS, GCS

• Pulm: breath sounds, secretions

• Cardiac: rhythm, JVP, edema

• GI: abdomen, last BM

• Renal: UOP

• Skin/Wounds

• Lines/Tubes

Assessment & Plan (by system)

Neuro: delirium, sedation, analgesia, SAT
Pulm: vent plan, weaning, imaging
Cardiac: shock, pressor goals, fluid responsiveness
Renal: AKI, electrolytes, CRRT
ID: antibiotics, cultures, source control
GI: PO vs TF, ulcer prophylaxis
Endo: insulin gtt, glucose
Heme: Hgb, platelets, transfusion needs
Lines/Tubes: day + need for removal
Prophylaxis: DVT, GI
Code Status / Family update