Clinical Snapshot & Problem List
1. Admission Assessment Details
1b. Diagnosis Builder
Diagnosis Builder — choose standard terms; add patient-specific details in final diagnosis.
Initial Treatment Plan — Pragmatic CDSS Draft
Treatment templates are editable documentation/order-set drafts. They do not execute orders. Verify patient-specific indication, contraindications, organ function, allergy, local formulary, antimicrobial policy, and consultant instruction before finalizing.
Full structured treatment plan (12 domains)
Comprehensive ICU Initial Treatment Order Builder
DRAFT - verify before prescribing/executing. Generated from the selected diagnosis/problem list, care bundles, and modifiers; the treating doctor remains the author and verifier of all orders.
2. Presenting History
3. Neurological Assessment
4. Respiratory Assessment
5. Cardiovascular Assessment
6. Renal Assessment
7. GI / Liver / Bleeding Assessment
8. POCT / Labs / Imaging (on admission)

ABG

CBC

Coagulation

Renal function & electrolytes

LFT

Inflammatory markers

Cardiac

Cultures

Imaging

9. POCUS
10. Co-morbidities
11. Organ Failure Assessment
Check applicable organ failures and document supporting severity/evidence. Do not trigger any intervention from a single parameter — at least three independent parameters or measurements should support an intervention.
12. Legacy manual treatment notes
Superseded by the "Initial Treatment Plan — Pragmatic CDSS Draft" section above. Kept for backward compatibility with older records; any text entered here is appended under LEGACY / MANUAL TREATMENT NOTES in the generated note, not as a second Initial Treatment Plan.
13. Family Communication
1. Shift Overview
2. Neurological
3. Respiratory
4. Cardiovascular
5. Renal
6. Hematology
7. Hepatic / Metabolic
8. Infection / Sepsis
9. Immune Suppression
10. Lines / Tubes / Support, Nutrition & Skin
11. Medications, Labs, Imaging & Procedures
12. Family Communication & Plan for Next Shift
1. Event Details
2. Clinical Findings
3. Assessment & Response
4. Communication & Plan
Treatment Modification / Rationale
Treatment templates are editable documentation/order-set drafts. They do not execute orders. Verify patient-specific indication, contraindications, organ function, allergy, local formulary, antimicrobial policy, and consultant instruction before finalizing.
1. Common Procedure Details
1b. Quick Core Fields (procedure-specific)
Key fields for the selected procedure, visible in quick mode. These fields move into this panel from the full detail section below (not duplicated) when a procedure is selected.
2. Procedure-Specific Details
Fields change based on the procedure selected above. Previously entered values for other procedure types are preserved even when not shown.
3. Procedure Narrative
1. Admission & Diagnosis
2. Clinical Course
3. Organ Support Required
4. Investigations & Microbiology
5. Current Status & Discharge Plan
1. Patient & Admission Details
2. Clinical Course
3. Resuscitation
4. Cause of Death
5. Family & Administrative
1. Clinical Details
2. Risk Counselling
3. Decision & Consent
4. Status at DAMA
1. Clinical Summary
This summary will state: "This summary is issued on request of family/attendant for treatment-related administrative / financial support purpose." Avoid inflated claims, outcome promises, or emotionally manipulative language.