Clinical
Intensive Care Charting
One chart per patient per day: hourly observations with the mean arterial pressure computed, CVP, urine output and fluid balance, sedation (RASS) and GCS, ventilator settings as they change, every line and tube with its days in, and the goals for the day reviewed at the evening round.
For:ICU nursesIntensivists
Where:Nursing › ICU Charts · on the admission: ICU chart today
How to
Open today’s chart
- On the admission (or from Nursing › ICU Charts), click ICU chart today; it is created if it does not exist.
- The header shows intake, output, balance and the lowest MAP so far.
Chart the hour
- Add the next hour: a row is created at the next hour; fill pulse, SBP/DBP (MAP computes), RR, SpO₂, temperature, GCS, RASS, pain, CVP, urine, other output, intake, glucose.
- A MAP under 65 or a saturation under 90 turns the row red; a GCS under 9 orange.
Record ventilator settings
- Ventilation tab › Add: time, mode (spontaneous, nasal cannula, mask, high-flow, NIV, volume control, pressure control, SIMV, pressure support, APRV), FiO₂, PEEP, tidal volume, rate, pressure support, peak and plateau pressures.
- Add a new line every time a setting changes; the previous ones stay as the history.
Track lines and tubes
- Lines and tubes tab › Add: type (CVC, arterial line, PICC, ET tube, tracheostomy, NG, urinary catheter, drains, epidural), site, the time inserted and by whom.
- Days in counts itself; past seven days the line is highlighted so the round asks whether it is still needed.
- Remove stamps the removal time; the device stays on the admission’s history.
Set and review daily goals
- Daily goals tab: write the plan at the morning round (wean, sedation hold, breathing trial, mobilise, feeds).
- Tick “reviewed at the evening round” when it has been.
See also: Nursing Station & Barcode eMAR Admissions & Bed Board