Received report from outgoing RN, labs, orders, medication profile, trends, plans and family dynamics reviewed. Assumed pt care.
Safety checks completed. Alarms set and armed. Emergency access and equipment present and in working order. Code status verified. Drip calculation, compatibility and allergies verified. Pt stable. Visible from nurses stations. Call button in reach. Bed low and locked. Room clear and well light. Will continue monitoring. See assessment section for systems review.
This is a sample ICU beginning shift RN note. It covers the report and safety checks that must be done within the first 15 minutes in a proper nursing world. On safety checks, you may want to add other things as applicable. Example include restraints, blood transfusions, special procedures in progress. You must show and acknowledge that you looked into them and did recommended safety checks from the word get go.
Donna Collins says
Thank you for entering: “How to write opening ICU Nursing Note.” There are no references to back this statement up. In Canada we practice evidence-based medicine. While medication profile is nice, specifically did the ICU Nurse examine for drug-drug interactions that prolong the QTc interval? There is no indication that the ECG was examined which is a gap in care. My evidence comes from ‘retrospective chart audits’ where patients died from premature and preventable death. Opiate overdose is a leading cause of death in hospitals and Narcan is the treatment to reverse it…if we remember! Also we need to not only check ‘CODE STATUS’ but determine if the patient is a suitable candidate for organ donation and retrieval. I have references if anyone wants them.
Saint John, NB Canada