How to Write ICU Rounds Notes as an Intensivist

Structure of an ICU Round Note

1. Header Line

• Date and time of the round
• Team members present (Consultant/Intensivist, Registrar, Resident, Medical Student, Nurse, Pharmacist)
• One-line patient summary

Example: ICU AM Round - Dr. Sharma / Dr. Patel / Dr. Rao 55M Day 6 ICU with severe community-acquired pneumonia, ARDS, septic shock, AKI on CRRT.

2. Active Problem List / Issues

# ARDS / Type 1 Respiratory Failure
# Septic shock (gram-negative bacteraemia)
# Acute Kidney Injury - on CRRT
# Metabolic acidosis
# Nutritional deficit

3. Overnight/Interval Progress

• Any acute deteriorations or improvements
• Medications given as needed (e.g., blood products, boluses)
• Procedures performed (e.g., line insertions, intubation, bronchoscopy)
• Consult responses received
• New culture results or imaging results

Example: "Overnight: transient hypotension at 02:00, responded to 500ml NS bolus. No new arrhythmia. Norepinephrine uptitrated from 0.1 to 0.15 mcg/kg/min."

4. Organ System Examination (Core of the Note)

A/B - Airway and Breathing (Respiratory)

• Airway status: self-ventilating / orally intubated / tracheostomy (size, day)
• Ventilator mode: VC-AC / PC-AC / SIMV / PSV / CPAP + FiO2
• Settings: Tidal Volume (TV), RR, PEEP, Pressure Support (PS), I:E ratio
• Peak/Plateau/Mean airway pressures
• SpO2, ABG results (pH, PaO2, PaCO2, HCO3, BE, Lactate)
• P/F ratio (PaO2/FiO2 - severity of ARDS)
• Lung compliance (static/dynamic)
• Secretions - amount, colour, suctioning frequency
• CXR changes
• Readiness for SBT (Spontaneous Breathing Trial) / extubation criteria

Example: "Orally intubated Day 6. VC-AC mode, TV 420ml (6 ml/kg IBW), PEEP 10, FiO2 50%, RR 16. ABG: pH 7.38, PaO2 82, PaCO2 44, HCO3 26, Lactate 1.2. P/F ratio 164 (moderate ARDS). Bilateral crackles, moderate secretions suctioned. CXR: bilateral infiltrates, no pneumothorax."

C - Circulation (Cardiovascular)

• Heart rate, rhythm (ECG if relevant)
• Blood pressure (invasive arterial vs. NIBP)
• MAP target and current MAP
• Vasopressors / inotropes: drug, dose, trend (escalating / weaning)
• CVP (if available)
• Cardiac output/index if PA catheter or PICCO used
• Fluid balance: current 24-hour balance and cumulative balance
• Peripheral perfusion: capillary refill, mottling, skin temperature
• Relevant cardiac investigations: Echo findings, troponin, NT-proBNP

Example: "HR 92 sinus, BP 108/62 (MAP 77) via arterial line. Norepinephrine 0.12 mcg/kg/min - stable, no escalation overnight. CVP 10 via CVC. 24h balance +400ml. Warm peripheries, CRT 2s. Echo D5: EF 50%, no wall motion abnormality."

CNS - Neurological

• Level of consciousness: GCS (E/V/M) or if intubated, E/V(T)/M
• RASS (Richmond Agitation-Sedation Scale) score - target vs. actual
• CAM-ICU (delirium screening) result
• Sedation agents: drug, dose, route
• Analgesia: drug, dose, NRS/CPOT pain score
• Pupillary response: size (mm), symmetry, reactivity
• Any focal neurology, seizure activity
• EVD details if present (height, output, colour, CSF pressure)
• Neurocritical care specifics: ICP, CPP, if applicable

Example: "E4VTM5, RASS -1 (target -1 to 0). CAM-ICU negative. Propofol 5mg/kg/hr, Fentanyl 25 mcg/hr. PEARL 3mm bilaterally. No new focal deficits."

GIT - Gastrointestinal / Nutritional

• Feeding: route (oral / NG / NJ / PEG / TPN), formula, rate, total calories delivered vs. target
• Gastric residual volumes (if relevant)
• Bowel status: last bowel movement, character
• Abdominal examination: soft / rigid / distended / tender
• NG/NJ tube position confirmed?
• Nausea/vomiting, prokinetics in use
• Liver: jaundice, LFTs trend, bilirubin
• Drains: type, site, output, character

Example: "NG feeds - Nutrison Protein Plus at 60ml/hr. Minimal aspirates. Abdomen soft, non-tender. Bowels opened yesterday. No nausea. Target 1800 kcal/day - on track."

GUT/Renal - Genitourinary / Renal

• IDC in situ - urine output (hourly, 24h, mL/kg/hr)
• Colour and character of urine (concentrated, haematuria, cola-coloured in rhabdomyolysis)
• AKI staging (KDIGO criteria): creatinine, urea trend
• Electrolytes: Na, K, Mg, Phosphate, Calcium
• Acid-base status related to renal function
• Renal replacement therapy (RRT/CRRT):
  • Mode: CVVHDF / CVVHF / IHD
  • Filter type, access site
  • Anticoagulation: heparin / regional citrate-calcium (CiCa) - circuit running well?
  • Dose (effluent rate mL/kg/hr), cumulative fluid removal target
  • Filter life, clotting issues

Example: "IDC: urine output 15-20 ml/hr, cola-coloured. CRRT Day 4 - CVVHDF via right femoral Vascath. CiCa anticoagulation, circuit running without issues. Target fluid removal -2L/24h - on track. Creatinine 280 (↓ from 360 yesterday). K+ 4.2."

ID - Infectious Disease / Microbiology

• Current active infections: site, organism, sensitivity
• Antibiotics: drug, dose, route, day number of therapy
• Culture results (blood, urine, sputum, wound): pending or resulted
• Fever chart: current temperature, trend, fever pattern
• WCC / CRP / Procalcitonin trend
• Duration of antibiotics, de-escalation opportunity, review date
• Indwelling lines - insertion date, site review (any signs of infection)
• Isolation precautions if applicable

Example: "Blood cultures Day 3: Klebsiella pneumoniae - sensitive to Meropenem. Day 5 of Meropenem 1g Q8h. Temp 37.6°C (down from 39.2° yesterday). WCC 11, CRP 85 (↓). Review at Day 7 for de-escalation."

H - Haematology

• Haemoglobin: trend, transfusion trigger and current threshold
• Platelets: trend (especially if on CRRT, HIT risk)
• Coagulation: PT/APTT/INR, fibrinogen
• Active bleeding or clotting events
• DVT prophylaxis: pharmacological (LMWH/UFH dose) or mechanical (TEDs/compression devices) - and reason if not on pharmacological
• Transfusion in last 24h: type, units

Example: "Hb 82 (stable). Plts 94 (↓, HIT screen sent). INR 1.6. No active bleeding. Mechanical DVT prophylaxis only (TEDs), pharmacological held given thrombocytopenia."

Endocrine / Metabolic

• Blood glucose: range over 24h, insulin infusion rate / sliding scale
• Target glucose range (typically 6-10 mmol/L in ICU)
• Adrenal insufficiency: hydrocortisone dose if on stress dose steroids
• Thyroid function if relevant
• Nutrition-related: phosphate (refeeding syndrome risk), Mg, Thiamine given?

Example: "BSL range 6.8-9.2 mmol/L on insulin infusion at 2 units/hr. Target 6-10. Phosphate 0.7 (low) - replaced. Thiamine given on admission."

Lines and Drains

Other

• Temperature and fever management: cooling measures, antipyretics
• Skin: pressure area care, wound status, any rashes
• Eyes: eye care for sedated/intubated patients
• Mouth care: oral hygiene (VAP prevention bundle)
• Physiotherapy: passive/active limb exercises, turns, early mobilisation status

5. Relevant Investigations

• New lab results reviewed (highlight abnormal trends)
• Imaging: CXR, CT, Echo - report findings or state "pending"
• Microbiology results
• Speciality consult notes reviewed

6. Assessment

"Day 6 in ICU with ARDS secondary to CAP. Respiratory mechanics improving - FiO2 weaned from 70% to 50%, P/F ratio improving. Haemodynamically stable, vasopressor requirements stable. AKI improving on CRRT. Bacteraemia on appropriate antibiotics. Overall: slow but consistent improvement."

7. Plan (Itemised by Problem)

# ARDS
- Continue lung protective ventilation (TV 6ml/kg IBW, PEEP 10)
- Wean FiO2 by 5% if SpO2 >95%
- SBT assessment tomorrow if FiO2 ≤ 40% and PEEP ≤ 8

# Septic shock
- Norepinephrine weaning protocol - reduce by 0.02 mcg/kg/min Q2h if MAP >65
- Continue Meropenem, review at Day 7

# AKI
- Target -2L fluid removal via CRRT
- Monitor electrolytes Q6h

# Nutrition
- Continue NG feeds at 60ml/hr, aim 1800 kcal/day
- Dietician review

# DVT prophylaxis
- Mechanical only (TEDs) - recheck platelets tomorrow, restart LMWH if >100

8. Daily Goals / Communication

• Goals for the day: specific, measurable (e.g., "wean FiO2 to 40%, achieve -2L fluid balance")
• Family communication: documented conversation, who was spoken to, what was communicated, next of kin's understanding of prognosis
• Goals of care / code status: documented and reviewed, especially if deteriorating or prolonged ICU stay
• Disposition plan: expected ICU stay, HDU/ward step-down criteria, rehabilitation needs

Key Mnemonics Used in ICU Rounds

FAST HUGS (Daily ICU checklist):

ABCDEF Bundle (ICU Liberation):

• A - Assess, Prevent, and Manage Pain
• B - Both SAT (Spontaneous Awakening Trial) and SBT (Spontaneous Breathing Trial)
• C - Choice of Analgesia and Sedation
• D - Delirium: Assess, Prevent, Manage
• E - Early Mobility and Exercise
• F - Family Engagement and Empowerment

Tips for Good ICU Documentation

1. Be specific with doses and settings - "vasopressors running" is not enough; write the exact drug, dose, and route
2. Show trends - "Creatinine 280, down from 360 yesterday" is far more useful than a single value
3. Document decision-making - if you chose NOT to transfuse at Hb 78, write why (stable, not bleeding, restrictive strategy)
4. Time-stamp key events - procedures, deteriorations, family discussions
5. Pre-round preparation - review overnight notes, nursing observations, labs, and imaging before rounds so the note reflects an informed assessment
6. Afternoon/evening rounds notes can be briefer - progress, targeted exam, plan for the overnight team with specific thresholds (e.g., "call if MAP <65 despite vasopressors, transfuse if Hb <70")
7. Document the overnight plan explicitly - this prevents unnecessary calls and ensures the night team knows what is expected
8. Lines review every round - unnecessary lines are a source of infection and should be removed as soon as no longer needed
9. Goals of care - review and document regularly, especially in prolonged ICU stays or deteriorating patients