Here’s the EPIC EMR template I made for rounding in the VAD/transplant ICU. The formatting is off (bold, centered, etc), but the shortlinks are still there for the problem list, problem list, recent vitals, VAD data, ins/outs, recent labs, scheduled medications, and infusion medications. Hope this helps at least one person! 🙂
VAD AND TRANSPLANT ICU – DAILY PROGRESS NOTE
Previous 24 Hours
***
Hospital Course
Hospital Day: @LOS@
Plan:
# Neuro
– ***
# CV
– ***
# Pulm
– ***
# GI and F/E/N
– ***
# Renal
– ***
# Heme
– ***
# Endo
– ***
# ID
– ***
# ICU Checklist
ASA |
Beta-blocker |
Glycemic Control |
Nutrition |
Restraints |
Need CVC? |
*** |
*** |
*** |
*** |
*** |
*** |
– DVT PPX: ***
– GI PPX: ***
– Analgesia: ***
– Lines/drains: ***
Problem List:
@PROB@
Physical Exam:
General: Alert and oriented, NAD
HEENT: Normocephalic, atraumatic, EOMI, vision grossly intact
Neck: No JVD, supple
CV: Audible pump hum, nonpulsatile on exam
Pulm: CTAB
Abd: Soft, NTND
Derm: Normal, no evidence of skin breakdown
Ext: Warm, well-perfused, no peripheral edema
Vitals:
@VSRANGES@
VAD Data:
|
I/O’s:
@IOBRIEF@
Labs:
@LABRCNT(wbc:3,hgb:3,hct:3,plt:3)@
@LABRCNT(na:3,k:3,cl:3,co2:3,bun:3,creatinine:3,calcium:3,mg:3,phos:3,ldh:3)@
@LABRCNT(INR:3,pt:3,ptt:3)@
@LABRCNT(tacrolimus:3,sirolimus:3)@
@LABRCNT(phart:3,pco2art:3,po2art:3)@
Diagnostics:
I have reviewed the relevant diagnostic imaging.
Microbiology:
I have reviewed the relevant microbiology.
Medications:
@MEDSSCHEDULED@
@MEDSINFUSIONS@
——————-
Rishi Kumar, MD
BCM Anesthesiology, PGY-3
VAD/Transplant ICU Team