Icu Flowsheet – Fill Out and Use This PDF

Updated: Nov 10, 2026

The ICU Flowsheet form is a detailed and comprehensive document used in the intensive care unit (ICU) to monitor and record the vital signs, assessments, interventions, and responses of neonatal patients critically. This form, utilized by Connecticut Children’s NICU at UConn Health Center, is meticulously designed to ensure that every aspect of a newborn's care is documented—from respiratory support to feeding behaviors and parental interactions. It plays a crucial role in ensuring high standards of care and facilitating effective communication among healthcare providers. If you need to fill out or review an ICU Flowsheet form for a patient, click the button below to get started.

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Icu Flowsheet PDF Details

At the Connecticut Children’s NICU at UConn Health Center located at 282 Washington Street, Hartford, CT 06106, the ICU Flowsheet form encompasses a detailed and structured approach to patient care, ensuring comprehensive assessments and standardized interventions for newborns and intermediate patients. This multifaceted form encapsulates vital aspects of patient identification, including stringent record-keeping of vital signs, pain assessments, respiratory support, and vital medical interventions across various shifts. Each section, from RN signatures to standards of care, underscores the meticulous attention to protocol and care techniques. Additionally, the form extends into patient and family teaching records, emphasizing the importance of caregiver education in the sustained well-being of the infant. Shift safety, encompassing alarms and equipment monitoring, ensures that all aspects of the patient's environment are conducive to health and recovery. The form meticulously records oral feeding attempts and responses, enteral and parenteral intake, and output, providing a comprehensive snapshot of the nutritional status of the patient. Supplemented by a breadth of standards for care, from kangaroo care to phototherapy, and including shift-specific standards for emergency and routine care, the ICU Flowsheet form is an indispensable tool in the management and documentation of neonatal care at the center. By integrating detailed patient assessments, care standards, and safety measures, the form facilitates a high standard of care and operational excellence in neonatal intensive care units.

Question	Answer
Form Name	Icu Flowsheet
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	dortoms, nicu flowsheet, nicu report sheet printable, nicu report sheet pdf

How to Fill Out Newborn/Intermediate Flowsheet

Newborn/Intermediate Flowsheet at a glance

What it is: The Newborn/Intermediate Flowsheet of Connecticut Children's NICU at UConn Health Center, 282 Washington Street Hartford, CT 06106, with a (Patient Identification) line and a Date.

A filled-in Newborn/Intermediate Flowsheet example: one charted hour

Newborn/Intermediate Flowsheet example filled out, example: one charted hour — A nurse charts one hour on the Newborn/Intermediate Flowsheet. At 0800 the heart rhythm is regular, breath sounds are clear and the skin is warm. Good air entry and good turgor go in the same boxes. Cord, fontanelle, activity, tone, cry and pain screen is left blank because the story charts none of them. Position/misc, oxygen mode, suction and CPT is left blank because the story charts none of them. The picture shows page 1, and its names and figures are sample values.

How to fill out Newborn/Intermediate Flowsheet, box by box

Date

Under (Patient Identification), enter the Date on the Newborn/Intermediate Flowsheet - Date line.

Bed, HR quality, resp. pattern and BP site

BED: I - Isolette, OC - Open Crib, OW - Open Warmer.

HR QUALITY: R - Regular, I - Irregular, M - Murmur. RESP. PATTERN: R - Regular, IR - Irregular, S - Shallow, PB - Periodic Breathing.

BP SITE: LA - Left Arm, RA - Right Arm, LL - Left Calf, RL - Right Calf, LT - Left Thigh, RT - Right Thigh.

Breath sounds, air entry, grunting and color

BREATH SOUNDS: Cr - Crackles, C - Clear, CO - Coarse, W - Wheeze, S - Stridor. AIR ENTRY: G - Good, L - Limited, T - Tight. RETRACTIONS: M - Minimal, MO - Moderate, S - Severe.

GRUNTING: A - Audible w/naked ear, S - Stethescope only, Int - Intermittent. COLOR: P - Pink, W - Pale, D - Dusky, C - Cyanotic, J - Jaundiced, PL - Plethoric, M - Mottled, A - Acrocyannosis. PERFUSION: N - CRT < 3 sec., A - CRT > 3 sec.

Skin temp, turgor, rash, edema and abdominals

SKIN TEMP: W - Warm, C - Cool, H - Hot, D - Diaphoretic. TURGOR: G - Good, F - Fair, P - Poor, C - Crepitus. RASH SITE: PA - Perianal, PN - Perineal, G - Generalized, T - Trunk. EDEMA: G - Generalized, Ex - Hands and Feet, PO - Periorbital.

Cord, fontanelle, activity, tone, cry and pain screen

UMBILICAL CORD: O - Off, D - Dry, W - Wet, Cl - Clamped, DG - Drainage. FONTANELLE: S - Soft, Flat, F - Full, T - Tense, B - Bulging, D - Depressed. ACTIVITY: ++ - Active, Alert, + - Active to stim, L - Lethargic, S - Sleeping, NC - Non-consolable, Q - Quiet.

TONE: N - Normal, J - Jittery, C - Clonus. CRY: L - Lusty, Vigorous, W - Weak, Hi - High-pitched, A - Appropriate for age, HO-Hoarse, Q - Quiet.

PAIN SCREEN: pain screen performed-no “triggers” for pain. *Refer to pain assessment scale.

Position/misc, oxygen mode, suction and CPT

POSITION/MISC: P - Prone, S - Supine, R - Rt. Side Down, L - Lt. Side Down, HOB - Head of Bed Up, HOB - Head of Bed Down, IS - Infant Seat, SW - Swaddled, SG - Swing, H - Held.

OXYGEN MODE: I - Isolette, H - Hood, NC - Nasal Cannula, MT - Mist tent, TC - Trach Collar. CPT: P - Percussion, V - Vibration.

SUCTION SOURCE: O - Oral, N- Nares. SUCTION AMOUNTS: Mo - Moderate, L - Large. TYPE: Th - Thin, Tk - Thick, C - Clear, W - White, Y - Yellow, G - Green, BRB - Bright Red Blood, P - Plugs, Br - Brown.

Fill in TIME, MODE, FiO2, FLOW, SPO2 TREND, Oximeter and SITE.

More rules for Newborn/Intermediate Flowsheet

STOOL COLOR: M - Meconium, Y - Yellow, G - Green, B - Brown, FB - Frank Blood. ENTERAL FEEDS MODE: Po - Nipple, BF - Breastfeeding, CNG - Continuous Nasogastric, NG/OG - Gavage.

BLOOD GAS SITE: HS - Heel Stick, VS - Venous Stick, FS - Finger Stick, Art - Arterial Stick. CIRC: CL - Clean, DG - Drainage, BL - Bleeding.

Under ORAL (PO) FEEDING DESCRIPTION, write Y or N for Attempt PO Y/N.

FORMULA TYPE/CALORIE: write #1, #2 and #3 on the lines.

Sources

[1] Newborn/Intermediate Flowsheet (Eff. 9/1/11), Connecticut Children's NICU at UConn Health Center (the Official source link on this page).