Respiratory Care Protocol Assessment Note

Date/Time of Assessment: [Date and time of assessment]

Location: [Facility / Unit / Bed]

Therapist: [Therapist name, credentials]

Protocol Order: [Ordering provider/service and protocol name]

Clinical Summary: [One-sentence key finding and action taken]

(Omit protocol elements not active for the patient. Use "Not assessed—reason" when an expected element is missing. Never autopopulate normal findings or imply stability/criteria met without documented supporting findings.)

Reason & Active Protocol

Reason for Reassessment: [routine interval / condition change / weaning evaluation / post-treatment response / nursing request / provider request / other: brief explanation]

Active Protocol: [Protocol name, patient-specific indication/goal, current therapy state (device/settings/frequency), and target endpoints] (Repeat for each active protocol; omit if none active.)

Assessment

(Combine subjective and objective findings relevant to protocol decision-making. Use short phrases and objective descriptors. If a clinically expected element is not obtained, document why rather than leaving blank.)

Subjective: [Patient-reported symptoms including dyspnea, tolerance, participation ability] (If communication limited, state limiting factor.)

Vitals/Oxygenation: [Relevant vitals, current device/settings, patient-specific target range]

Respiratory Exam: [Work of breathing, appearance, auscultation findings by location, cough/secretions if bronchial hygiene involved]

Contraindications/Holds: [Protocol-relevant contraindications or hold parameters] (Omit if none.)

Ventilator/Weaning Data: [Interface, mode, key settings, spontaneous parameters, recent ABG/capnography if applicable] (Include only if ventilated and weaning protocol applies.)

Protocol Criteria & Action

Score/Criteria Used: [Tool name with key component inputs, total score, and severity interpretation per institutional definitions]

Protocol Decision: [followed / deviated] (If deviated, provide explicit rationale and whether provider was contacted.)

Changes Made: [Each change in before → after format with protocol basis and time executed; include treatments administered/performed this encounter] (Omit if no changes made.)

Safety/Tolerance: [Adverse events, intolerance, or termination criteria met and actions taken] (Omit if encounter uneventful.)

Response & Plan

Response to Therapy: [Pre → post changes in SpO₂, respiratory rate, work of breathing, breath sounds, and patient-reported symptoms as relevant] (Anchor all statements to objective findings; avoid vague language like "tolerated well" without measurable support.)

Provider Notification: [Trigger criterion; who notified (role/name); time and method; message content; provider response/orders; read-back confirmation] (Include only if notification occurred.)

Plan: [Continue/adjust/discontinue status for each active protocol with device/settings/frequency; next reassessment interval; triggers for earlier reassessment; monitoring instructions for nursing/RT; discontinuation criteria if relevant]

Patient Education: [Topic, method, and outcome] (Include only if meaningful teaching occurred.)

Therapist Signature: [Authenticated signature with credentials]