ICU Note. Shift Change documentation in Cardiac Intensive Care Unit

I just thought I should write several sample ICU change of shift nursing notes, the way I know how to. You are more than welcome to comment with your version of ICU change of shift nursing note. There is no one way better than the other. It depends on the issues you want to address and the areas you want to cover.

While these nursing notes may appear defensive, to some extent, I like covering high risk areas and actually verifying these areas with outgoing nurse (RN). I just do not want to be found in a situation where I cannot tell what is going on where, when, how and why. I want to be able to tell most of what is going on with the patient before the outgoing RN leaves. These are “my 3 samples” of ICU change of shift nursing notes.

ICU Change of Shift Nursing Note For a Vented Patient: – Incoming

Received report from outgoing RN at bedside. Introduced self to the patient and family. Orders, trends, labs, plans and family dynamics reviewed. Code status verified, emergency access and equipment present and in working order. Drips calculation verified with outgoing RN. Alarms set, armed and audible. Ventilator settings verified per MD orders. Assumed patient care. Will continue monitoring.

ICU Change of Shift Note: – Outgoing

Report given to incoming RN at bedside, orders, trends, labs and plans reviewed. Drips calculation verified. Emergency access and equipment present and in working order. All questions answered. handed over patient care to John Doe, RN.

Those are my 2 samples on ICU nursing notes at change of shift. Feel free to comment with your version of ICU RN note at change of shift.

Chhers