How to write nursing notes ICCU?

How to write nursing notes ICCU?

First :
department or direct admission ...... others

Second :
As a case of ………. , Hx. …………,

Third :
conscious or unconscious ,oriented or disoriented (place , time , person ).

Fourth :
1: Breathing spontaneously via room air or nasal cannula , face mask
2: Breathing Via (ETT level … cm) or (Tracheotomy tube) with mechanical ventilation setting:
(Mode) : CMV, SIMV, CPAP , and NICMV, NICPAP , NISIMV, (FIO2) : …. % ,
(PEEP) : ……. CmH2o,
(P.S) : ……..CmH2o,
(T.V) : ……...ML,
(R.R) : ………/min,

Fifth :
patient connected to ECG monitor show ..( Normal Sinus Rhythm , Tachycardia , Bradycardia , Atrial fibrillation, PVCs,…….

Sixth :
patient with (example: ) : Right subclavian CVP line , NGT, PEG tube ,left arterial line radial and all access and infusion drugs and fluid .

Seventh :
any specific for patient , example : bed sores , ulceration , injury ,…

Eighth :
Urinated (folly's catheter ,or suprabubic , or condom catheter or freely ) with good urine out put , or oligura or anurea or polyurea ) .

Ninth :
any procedure and Dr. order on time to time