Designed for residents, fellows and medical students working in the neuro-ICU, this rounding worksheet helps you track important events in a patient’s clinical course and be prepared for rounds.
The sheet allows for 6 days of tracking. For more than 6 days, print the “Back” sheet alone and use it to continue tracking the patient.
This is a 2-sided form that helps you track neuro-exam, labs, imaging, ventilator parameters, EVD output and settings, and CSF findings over time for an individual patient.
HPI and background information is entered on the front, and on the back is a daily update form.
I typically print about as many forms as patients that I anticipate seeing in the neuro-ICU in a week, staple them together then walk around with the forms in my lab coat.
Only non-standard abbreviations are noted.
Tm – 24-hour maximum temperature
O2 – SpO2 (oxygen saturation)
I/O/Nd/Nt – Input / Ouput / Net daily in-out balance / Net in-out balance for hospital stay
o/n – overnight events
MS – mental status exam findings
CNs – cranial nerve exam findings
Endo BS – endocrinology and blood sugar management
EVD o/p ml – 24 hour output in milliliters of EVD
ICP – intracranial pressure measured from EVD
CPP – cerebral perfusion pressure estimated from mean arterial pressure (MAP) – ICP
Prot – CSF protein level
gstn – CSF gram stain
LED – lower extremity doppler study (used to check for DVT)
BM record – note date of last bowel movement
Cx – culture (eg. Ur cx means urine culture)
HSQ – heparin sub-cutaneous
SSI – sliding scale insulin; “L M H” are low- medium- or high-dose sliding scale protocols
MRA/carUS – refer to head/neck vascular studies (either MRA or carotid ultrasound)
DOA – date of admission
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