ICU and other critical care areas requires critical charting where every dimension of care and safety is fully and well documented. As a critical care nurse, I always start my note with the first thing that happened right at report. Since my title is about how to start an ICU nursing note, I will document the first 30 minutes or so. To make it simulated and look real, I will use time brackets.
0700: Received report from outgoing RN, orders, labs, medication administrations, pending interventions, patient trends and family dynamics reviewed, questions answered, assumed patient care. (Remember nursing note does not have to follow grammatical rules)
0715: Introduced self to the patient, safety checks: – alarms set and armed, emergency access identified, emergency equipments present and in working order, arm band on and legible, allergy band on, code status verified.
0730. Assessment completed, see ICU flow sheet. (Document abnormal finding and actions/interventions carried out). Pt c/o pain on the right back chest pain, vital signs recorded, MD notified, new orders for Nitro s/l, cardiac enzymes, EKG and bed rest ordered. Dr Smarty Pants by bedside.