Noninvasive Ventilation Note (CPAP/BiPAP)

Note Type: [Initiation/Setup / Reassessment/Follow-up / Wean/Discontinue]

Date/Time: [Date and time of documentation]

Time NIV Started: [Clock time NIV initiated] (Only include if different from note time)

Location: [Care setting and bed/room]

Author/Role: [Name, credential, and role]

Device: [CPAP / BiPAP-Bilevel (specify mode if applicable)]

Indication: [acute hypercapnic respiratory failure / cardiogenic pulmonary edema / hypoxemic respiratory failure / post-extubation support / neuromuscular weakness / obesity hypoventilation / OSA (home CPAP continuation) / palliative symptom relief / other]

Code Status/Escalation Intent: [Full code - intubate if NIV fails / DNI - NIV as ceiling / Other limited plan]

(Time linkage is mandatory—always pair physiologic values with exact assessment time and concurrent NIV settings. For safety-critical items—airway protection status, skin check, escalation plan, reassessment timing—if not yet assessed, document "Not assessed yet - planned at [time]" rather than omit.)

Indication and Safety Screen

[Primary reason NIV is being applied now (diagnosis and relevant physiology)] [Therapeutic intent (trial to avoid intubation, bridge therapy, post-extubation support, or comfort/symptom relief)] [Safety screening summary: airway protection and mental status; hemodynamic stability; ability to cooperate and use interface] [If using despite relative contraindications, include brief justification and note enhanced monitoring level] (Write 2–4 sentences. For reassessment notes, update only if clinical context or safety status has changed; otherwise state "unchanged from initiation.")

Interface and Settings

Interface: [Type (oronasal/full face/nasal/helmet), size, fit assessment, leak quality]

Skin Check: [Sites inspected and findings; preventive measures in place; if deferred, state reason and planned recheck time]

Mode/Pressures: [CPAP pressure or IPAP/EPAP; backup rate and Ti if applicable]

Oxygen: [FiO2 or flow rate with delivery method; target SpO2 range]

Other Parameters: [Humidification, rise time, trigger/cycle adjustments if relevant] (Omit if standard settings)

Device Data: [Observed values (leak, tidal volume, minute ventilation) with time] (Mark as "verified at bedside" or "imported - pending verification")

Response to NIV

Pre-NIV (or prior assessment) at [time]: [RR; SpO2 with O2 device/FiO2; work of breathing/accessory muscle use; mental status; ABG/VBG with values and time if obtained]

On NIV at [time] (settings: [key settings]): [RR; SpO2; work of breathing; mental status; ABG/VBG with values and time if obtained]

(Add additional "On NIV at [time]" entries if multiple reassessments occurred; each must include concurrent settings. If no blood gas available, state why and what alternative monitoring is used.)

Tolerance: [Comfort; anxiety/claustrophobia; leak issues; patient-ventilator synchrony; sedation if used with agent/dose/goal]

Adverse Effects: [Gastric distension / skin injury / hemodynamic changes / none observed]

Interpretation: [Improving / Stable / Worsening] (One-sentence justification tied to objective data above)

Plan

• NIV Plan: [Continue current settings / Titration planned with rationale / Wean trial / Discontinue]
• Monitoring: [Next reassessment time; blood gas timing if planned; who will reassess]
• Escalation Triggers: [Specific objective criteria prompting urgent review or intubation evaluation—include parameters and thresholds] (Required at initiation; update if criteria change)
• Underlying Cause: [Brief note on treatment of precipitating condition]
• Disposition: [Appropriate care level; ICU/step-down involvement if applicable]