In the fast-paced environment of the intensive care unit (ICU), precise and thorough patient documentation is critical. One of the most effective ways to maintain high-quality documentation is through the consistent use of templates. The ICU Ward Round Note, utilizing the ABCDEFGHIL assessment, is a prime example of structured documentation that ensures comprehensive patient care. In this guide, we will delve into how to correctly write and format this clinical documentation, using a detailed example for each section of the template.

The ABCDEFGHIL assessment is a systematic approach to ICU documentation, covering critical aspects of patient care. Let’s break down each component with an example using our template:

A - Airway

Document the status of the patient’s airway. For instance, "The patient's airway is patent with an endotracheal tube in place, receiving mechanical ventilation."

B - Breathing

Include details about ventilator settings and respiratory status. Example: "The patient is on a ventilator with settings of FiO2 50%, PEEP 5 cmH2O, and tidal volume 450 mL. Oxygen saturation is maintained at 95%."

C - Circulation

Record cardiovascular stability and interventions. Example: "Blood pressure is stable at 120/80 mmHg, heart rate is 85 bpm. The patient is on norepinephrine infusion at 5 mcg/min."

D - Disability

Note neurological status and sedation levels. Example: "Neurological status: GCS score is 9, the patient is sedated with propofol infusion."

E - Exposure/Environmental Control

Assess skin condition and electrolyte balance. Example: "Skin is intact with no pressure ulcers. Electrolytes show sodium 140 mmol/L, potassium 4.0 mmol/L."

F - Fluid Balance

Document fluid input and output. Example: "Fluid balance is positive with 2 liters input and 1.5 liters output. Urea is 8 mmol/L, creatinine 90 µmol/L, GFR is 75 mL/min."

G - Gastrointestinal/Nutrition

Include nutritional support and liver function. Example: "The patient is receiving enteral nutrition via a nasogastric tube. Liver function tests are within normal limits."

H - Hematology

Record hematological status. Example: "Hematological status: Hemoglobin is 12 g/dL, no transfusions required."

I - Infection/Immunity

Include temperature and infection control measures. Example: "Temperature is 38.5°C, blood cultures are pending, on broad-spectrum antibiotics."

L - Lines, Tubes, and Drains

Document the status of any lines or tubes. Example: "Central venous line and urinary catheter in place, functioning well."

Following the ABCDEFGHIL assessment, the FASTHUGS mnemonic is used to ensure holistic patient care, addressing Feeding, Analgesia, Sedation, Thromboprophylaxis, Head-up position, Ulcer prophylaxis, and Glycemic control.

Incorporating AI technology, such as the Notis AI Medical Scribe, can transform the documentation process for intensive-care specialists. Notis leverages advanced voice-to-text technology to create structured SOAP notes, significantly reducing the time spent on administrative tasks. With Notis, healthcare professionals can focus more on patient care rather than documentation.

Notis offers seamless integration through platforms like WhatsApp, providing a familiar interface that eliminates the need for additional software. Its high accuracy in transcribing medical notes, coupled with multilingual support, makes it an invaluable tool for diverse ICU settings.

By automating the creation of medical notes, virtual scribes like Notis improve efficiency, accuracy, and consistency in patient documentation. This not only enhances patient care but also helps reduce clinician burnout by saving up to two hours per day on documentation tasks.

In conclusion, mastering the ICU Ward Round Notes using the ABCDEFGHIL template ensures comprehensive patient assessment and care. When combined with AI medical scribes, intensive-care specialists can further streamline their workflow, allowing them to dedicate more time to what matters most—patient care.