Critical Care Nurse Practitioner: History & Physical Note Example

Note writing is something I had minimal training on while in my graduate nursing program. Yes, I knew disease processes and appropriate interventions. But, when it came to assembling, formulating, and getting those thoughts on paper professionally - I wasn't prepared. I had to intentionally request that my employer educate and train me on this process. Note writing is not merely writing what occurred, without format, intention, and purpose. Specific items must be included in the note for billing purposes. As an advocate for your organization and your patient, you want to make sure your group receives the appropriate compensation for services rendered and that you meet all the medical requirements on your patient's behalf. 

As a critical care nurse practitioner, my notes include everything and anything related to my patient. I take the time to sit with the patient (and their loved ones) and let them tell me what happened. I don't know what is important until I hear it. So I just listen. I write the full story and my notes are broken down by body systems. Note writing requirements differ depending on what specialty you work for. Some providers write notes based on problems only. The top two options are body systems (e.g., neurological, pulmonary, cardiovascular, etc.) vs problem-based (e.g., DKA, SIRS, acute respiratory failure) documentation, in my experience. An example of my body system based formatting will be below. 

Seems crazy long, huh? I have a template, it takes me 10-25 minutes. I do this 2-5 times per shift (on night shift), depending on how many admissions and consults I receive. I also use M*Modal verbal transcription too, which makes it even faster. Now, each organization and specialty is different. What works for me might not work for you or your organization's needs. Always ask your employer was is needed. For example, when I worked on a cardiothoracic surgery service line, and the surgeons required a 10- to 13-point review of systems for all consultations. Any fewer and proper reimbursement couldn't be achieved. Even if you think you know, ask anyway. Now, these notes don't include my current ICU patients, who can range from 16-28 individuals that require monitoring, prompt follow-through and efficient management. Meaning, I can't spend an hour writing a note. The goal is proficiency and timeliness.

Note: This is an example - not factual, not an actual patient, not an actual experience. Don't expect to diagnose anything with the information below. They are just words in a somewhat cohesive order (haha) to show my formatting. Don't overthink it.

History of Present Illness

Due to clinical condition, HPI obtained from patient's wife, medical records and medical staff

Patient is a 50-year-old male, with PMHx of CAD s/p PCI (DES to mid LCX, mid LAD), severe AS (s/p aortic valvuloplasty), PAF (s/p ablation), NICMO, HFrEF (EF 20-25% as of 04/2020), HTN, CKD stage 3B/4 (baseline creatinine 2.2-2.4), COPD (2L oxygen dependence) and IDDM2, who presented to the ED (via EMS) post-cardiac arrest. The patient had initial complaints of dyspnea and SOB (at rest) x 24 hours (while on 2L N/C oxygen at home). The patient's wife called 911 for support. En route with EMS, the patient went into PEA. CPR was performed and epinephrine IVP x2 was administered with ROSC achieved en route (total time was 8 minutes). CXR upon arrival revealed multifocal pneumonia with moderate BL pleural effusions. In the ED, the patient received cefepime, vancomycin and lasix 120 mg. Upon ED arrival, the patient did not withdrawal to pain and did not follow commands. Therapeutic hypothermia protocol initiated.

Upon ED assessment: GCS 6, patient VSS (on vent - CMV 24/500/8/50%), does not follow commands, does not withdrawal to pain, in no acute distress. The patient to be admitted to ICU for further monitoring and management of care. 

*Home medications unknown at this time, wife will bring list tomorrow.

Review of Systems

Unable to obtain d/t clinical condition

Histories

Information obtained from patient's wife and medical records

Past surgical history: PCI x 2 (DES), valvuloplasty, ablation

Pertinent family history: Noncontributory

Living situation: Lives at home, with wife

Tobacco use: Never, denies 

Alcohol use: Seldom, socially 

Illicit drug use: Denies

Assessment

Cardiac arrest, PEA-ROSC (8 minutes)

    Respiratory vs. CHF etiology

Encephalopathy s/p ROSC

Multifocal pneumonia, POA

Bilateral pulmonary effusions

AKI on CKD

    CKD stage 3B/4

    Baseline creatinine 2.2-2.4

Hyperglycemia 

Leukocytosis 

Gray zone troponin 

Elevated proBNP 

Elevated procalcitonin 

HTN, chronic

CAD, chronic 

    DES - LCX, mid LAD

HFrEF (EF 20-25%), chronic

NICMO, chronic

COPD, chronic

IDDM2, chronic

Severe AS, chronic

    S/p aortic valvuloplasty 

Plan

Neurological

-Neurological assessments per unit protocol

-Pain & sedation infusions

    RASS Goal -1 to -2

-PT / OT / Speech evaluations ordered

-CT Head results noted:

    No evidence of acute intracranial abnormalities.

-Therapeutic hypothermic protocol initiated

-EEG / MRI once off sedation / rewarmed

-Neurology consulted

Cardiovascular

-Arterial line / CVC inserted

-Maintain SBP > 90 < 160 & MAP > 65

-Flotrac monitoring 

    Hemodynamics q4hr

-12 Lead EKG q8hr

-Lactic acid q6hr

-ECHO

-BLE Doppler

-Serial troponins

-Cardiology consulted

Pulmonary

-IPPV, wean as tolerated

-Maintain O2 sat > / = 92%

-Scheduled BD / ICS

-Lung protective strategies

-CXR & ABG in AM

-CXR results noted:

    Mixed interstitial and alveolar airspace opacities throughout the lungs.

    Multifocal pneumonia with bilateral moderate pleural effusions. Cardiomegaly.

Gastrointestinal / Nutrition

-NPO

-OGT to LIS

-Nutrition consulted

    Tube feeding mgmt

Renal

-Strict I & O

-Monitor UOP

-Trend BUN/Cret

-Monitor / replace electrolytes

-Nephrology consulted

Infectious Disease

-Monitor C&S / fever curve / WBC

-Respiratory PCR

-Empiric antibiotics (Cefepime / Vanco)

-Procalcitonin level

-Pan Cx

Endocrine

-Insulin gtt, per protocol

-Goal BG < 180 

Prophylaxis

GI: Pepcid

VTE: Heparin SQ

DISPO: ADMIT TO ICU

CODE STATUS: FULL CODE

----------------------

Patient admitted to ICU for close monitoring due to their critical illness

Plan of care discussed with RN, RT, attending MD (Dr. John Smith)

Time includes personal review of any labs, microbiology results, EKG tracings, and/or imaging studies.

CCT: 35 minutes