UVA CHILDRENS HOSPITAL PICU DAILY PROGRESS NOTE Virginia Form

Understanding the UVA Children's Hospital PICU Daily Progress Note

The UVA Children's Hospital PICU Daily Progress Note is a structured document designed for healthcare professionals to record patient information in the Pediatric Intensive Care Unit. This note captures critical details about a patient's condition, treatment plan, and responses to interventions. It serves as a vital communication tool among medical staff, ensuring continuity of care and compliance with medical standards.

Steps to Complete the UVA Children's Hospital PICU Daily Progress Note

Filling out the PICU Daily Progress Note involves several key steps:

• Begin by entering the patient's identifying information, including name, date of birth, and medical record number.
• Document the date and time of the note to maintain accurate records.
• Assess the patient's current status, including vital signs, physical examination findings, and any changes in condition.
• Summarize the treatment provided since the last note, including medications administered and procedures performed.
• Note any new orders or changes to the treatment plan, ensuring clarity for all team members.
• Conclude with a summary of the patient's progress and any anticipated needs for the upcoming shift.

Key Elements of the UVA Children's Hospital PICU Daily Progress Note

Essential components of the PICU Daily Progress Note include:

• Patient Information: Basic details such as name, age, and medical record number.
• Clinical Assessment: Current vital signs and physical exam results.
• Interventions: A summary of treatments administered and their effectiveness.
• Plan: Future treatment strategies and any required follow-up actions.

Legal Use of the UVA Children's Hospital PICU Daily Progress Note

The PICU Daily Progress Note must adhere to legal standards to ensure its validity. This includes maintaining patient confidentiality in compliance with HIPAA regulations. Proper documentation is critical, as it can be used in legal contexts to demonstrate the quality of care provided. Ensuring accuracy and completeness in the note can protect healthcare providers from potential liability.

Obtaining the UVA Children's Hospital PICU Daily Progress Note

Healthcare professionals can obtain the PICU Daily Progress Note through the hospital's electronic medical record system or by requesting a physical copy from the hospital administration. It is essential to ensure that the most current version of the note is used to comply with hospital protocols and legal requirements.

Examples of Using the UVA Children's Hospital PICU Daily Progress Note

Examples of effective use of the PICU Daily Progress Note include:

• Documenting a patient's recovery progress post-surgery, highlighting improvements in vital signs and mobility.
• Recording changes in medication dosages based on a patient's response to treatment.
• Communicating critical information during shift changes to ensure continuity of care.