Get Micu Intern/resident Daily Progress Note - University Of Virginia - Virginia

Filling out the Micu Intern/resident Daily Progress Note is an essential task for medical professionals working in the critical care environment. This guide provides clear and concise instructions to help users complete the form accurately and efficiently online.

Follow the steps to successfully complete the daily progress note.

1. Press the ‘Get Form’ button to access the Daily Progress Note and open it in the designated editing interface.
2. Enter the date of the note in the provided field at the top of the form.
3. Indicate the time at which the note is being filled out.
4. In the 'History and Chief Complaint' section, provide a brief summary of the patient's current condition and primary complaints.
5. Proceed to the 'Physical Examination' section. Fill in the relevant fields including maximum temperature (Tmax), temperature (Tc), respiratory rate (RR), oxygen saturation (SaO2), blood pressure (BP), and pulse (P). Use the appropriate notations for the general appearance (Gen), head, ears, eyes, nose, throat (Heent), neck, lungs, heart, abdomen (ABD), extremities (Ext), and neurological (Neuro) assessments.
6. Document any medications, IV fluids, pressors, and nutritional information in the designated section.
7. Record critical care data, including fluid intake and output, results from chest X-rays (CXR), ECG findings, and ventilation settings specified as mode and settings (tidal volume, rate, pressure level, FiO2, PEEP).
8. For right heart catheterization data, document the pulmonary artery systolic and diastolic pressures (PAS/PAD), pulmonary capillary wedge pressure (PCWP), and systemic vascular resistance index (SVRI).
9. Report arterial blood gas (ABG) results including pH, cardiac index (CI), pulmonary vascular resistance index (PVRI), partial carbon dioxide pressure (PcCO2), and partial arterial oxygen pressure (Pao2). Add any other relevant information in the 'Other' section.
10. In the 'Problem List' section, list any pertinent problems identified during the assessment.
11. Outline the plan of care under various specialities including CNS, pulmonary (PULM), cardiovascular (CV), gastrointestinal (GI), renal (RENAL), infectious disease (ID), hematology (HEME), endocrinology (ENDO), and any other specialties relevant to the patient's case.
12. Complete the resident signature section, providing your signature and the current date.
13. In the attending note section, the attending physician or supervising clinician should sign, confirming their examination of the patient and revising or confirming details as documented by the resident.
14. After all fields have been filled out, save your changes, and choose to download, print, or share the completed form as necessary.

Complete your Micu Intern/resident Daily Progress Note online today!