Notes are done in the computer record (EPIC). A separate note documenting pertinent exam findings, clinical trajectory, and critical care plans should be created for both the day and night shift (it is acceptable to “add on” to the day note with updates from the night shift; but you should never edit or overwrite a prior piece of documentation, make a separate note ). “Copying/pasting” patient information and plans should be avoided. To begin a note, select the “Notes” button. Choose Type of Note from the dropdown menu. Type “SICU” in the SmartText field to pull up templates to notes used in the SICU. Complete all pertinent fields paying particular attention to the active problem list.
The “date of service” for your note should be the date at the start of your shift. It is very important that this is accurate, especially on night shifts.