Date :  

                                                           Day in ICU /

Postop Day :                                           
Name :                                                                                                               R/N :
                                   Sex :                Male  /  Female                
INTENSIVE CARE CHART !!
HOSPITAL                                                              
ALLERGY
Referring Unit :                                                                                                       Staff-in-charge : morning
:
Diagnosis :                                                             Age :                                   
                                                            I/C :                                   
Weight :                   kg   BMI :                  
Height :                   cm  IBW:                  
KEMENTERIAN KESIHATAN MALAYSIA
afternoon :                                                                           
night :                                                                           
EVENTS 0700 0800 0900 1000 1100
Values above scale
mmHg
180
160
Invasive Blood Pressure

Systolic BP v 140
Diastolic BP
MAP - 120
1200 1300 1400 1500 1600 1700 1800 1900 2000

180

160

140

120
2100 2200 2300 2400 0100 0200 0300 0400 0500

180

160

140

120
0600 ETT or Tracheostomy

180

160

140

120
 Morning Afternoon Night

Size (mm)

Level (cm)

Cuff pressure (mmHg)

Non - Invasive Blood Pressure Systolic BP v 100
Diastolic BP MAP - 80
60
100
80
60
100
80
60
100
80
60
Examination of Catheter Insertion Site
Write eg - Clear - Pus
- Oozing - Swollen
- Hematoma
 Morning Afternoon Night

Arterial line

Central venous catheter

Dialysis catheter

Peripheral catheter 1
2
Heart Rate ● 40
Values below scale CVP
CO / CI SVR / SVRI
Temperature °C
Ventilator model / Ventilatory mode FiO2
RR / Frequency Set
Total
40 40
40
Insertion & Removal of Catheter
 Indwelling Catheter Site Date & Time of Date & Time of
Insertion Removal
Arterial line

Central venous catheter

Dialysis catheter

Peripheral catheter 1
2

Nasogastric tube

Urinary catheter

ICP monitor catheter

Drain 1
2
3
I : E ratio TH : TL
Volume Set
Expiratory
Pressure Set
Peak Plateau
Nebuliser / MDI
pH cK+
pCO2 cNa+
pO2 cCa2+
HCO3 (Actual) cC ˉ
BE (B) P/F
Monitori
Lactate Glucometer ng of
Glasgow coma score (total score) Pressur
Eye opening / Verbal response / Motor response Pupils
R size ± L Size ± Limb Movements RUL LUL e Ulcer
RLL LLL Morning
Intracranial pressure / CPP (mmHg)
Afternoon
YES / NO
1
Night
Sedation score CAM-ICU
Pain score
Drip 1 (Arterial line / CVL) 2
3
Infusion 1
Infusion 2
Infusion 3
Infusion 4
Infusion 5
Infusion 6
Infusion 7
Infusion 8
DAY if Site 2
TOTAL yes 3
1
Size 2

3
1
Stage 2
3
Oral / Enteral
Stat medication Route
TOTAL
CRRT / HD
Drain 1
Drain 2
Drain 3
Gastric aspirate Nature/Volume

Bowel movement Nature

Urine
TOTAL
HOURLY FLUID BALANCE CUMULATIVE FLUID BALANCE
Mouth care / Eye care
Positioning
Balance for the day :                                         
 Morning Afternoon Night

YES / NO

If yes, Visited
by
 In
Out