Respiratory Therapy Initial Assessment Note (Inpatient)

Note type: Respiratory Therapy Initial Assessment - Inpatient

Date and time of service: [Service date and time]

Facility, unit, room, and bed: [Facility / Unit / Room / Bed]

Patient identifiers: [Patient identifiers per facility policy]

RT name and credentials: [RT name, credentials]

Ordering provider or attending: [Provider name and role]

Admission date: [Admission date]

Late Entry: Service: [Original service date/time] | Documented: [Entry date/time] — [Reason for delay] (Include only if documentation is delayed.)

Indication for RT Encounter

[Trigger type: provider order / RT-driven protocol initiation / consult]; [Primary clinical indication for RT services, e.g., hypoxemia, increased work of breathing, bronchospasm, secretion retention, post-operative lung expansion, airway management] (Summarize in 1–3 sentences. If indication is unclear from the order, state that chart review was performed and note any provider notification per policy.)

Data Sources and Limitations

• Sources: [Patient interview / family or caregiver / chart review / device data / nursing notes]
• Limitations: [Factors affecting assessment: intubation, sedation, language barrier, delirium, inability to perform maneuvers, infection control restrictions] (Omit if none.)
• Unable to assess: [Critical safety information not obtainable with reason] (Document explicitly rather than leaving blank.)

Respiratory History

Presenting respiratory symptoms: [Symptoms at presentation; onset, duration, and course; progression since admission; associated factors]

Baseline functional status: [Usual exertional tolerance; baseline oxygen requirement if any; prior intubations or NIV use; relevant prior hospitalizations]

Pulmonary and medical history: [COPD / asthma / bronchiectasis / ILD / OSA / neuromuscular disease / heart failure / recent thoracic or upper abdominal surgery / aspiration risk factors] (List applicable conditions only.)

Home respiratory regimen: [Home oxygen: device, flow, timing; CPAP/BiPAP: settings, interface, adherence; inhaled medications and delivery method; airway clearance equipment] (If unknown, state "home regimen unknown" with reason.)

Tobacco and exposures: [Current / former / never; pack-years if available; other exposures only if directly relevant to current care]

Current Respiratory Devices and Settings

(Include only applicable subsections; omit those that do not apply.)

Oxygen therapy: [Device type]; [Flow or FiO2]; [Humidification: yes / no]; [Ordered SpO2 target range]

Aerosol therapy: [Medication and dose]; [Delivery device]; [Frequency]

Noninvasive ventilation: [Interface type and fit]; [Mode]; [Settings: IPAP/EPAP or PS/PEEP, FiO2, backup rate]; [Skin integrity at interface sites]

Invasive mechanical ventilation: [Airway type, size, position reference]; [Mode and settings: Vt or PC target, RR, PEEP, FiO2]; [Measured values: exhaled Vt, MV, peak/plateau pressures]; [Alarm settings]; [Humidification method]

Artificial airway: [Airway type and size]; [Cuff status and pressure]; [Suction setup availability]; [Securement integrity]; [Stoma or skin condition]

Objective Respiratory Assessment

• General appearance and work of breathing: [Level of consciousness; position; visible distress; accessory muscle use; retractions; nasal flaring; speech limitation; respiratory pattern]
• Vital signs: RR [value], HR [value], BP [value], Temp [value], SpO2 [value] on [device] at [FiO2], EtCO2 [value if monitored], Pain [score if relevant]
• Lung examination: [Auscultation findings by region; adventitious sounds with location; diminished or absent breath sounds; chest expansion symmetry]
• Cough and secretions: [Cough effectiveness]; [Secretion amount and character]; [Suctioning performed, results, and patient tolerance] (Include when relevant to presentation.)
• Artificial airway assessment: [Position and securement integrity]; [Cuff pressure]; [Stoma or skin condition]; [Speaking valve status]; [Safety concerns and actions taken] (Include only if airway present.)
• Patient-ventilator assessment: [Mode and settings]; [Exhaled Vt with mL/kg PBW]; [Plateau and driving pressure]; [Auto-PEEP if present]; [Synchrony observations]; [Humidification adequacy] (Include only if on NIV or IMV.)

Diagnostics Reviewed

• Blood gases: [ABG or VBG values with date/time]
• Imaging: [Pertinent findings per radiology report with study type and date]
• Labs: [Hemoglobin, WBC, or other pertinent values with date]
• Microbiology: [Culture or PCR results affecting isolation or airway management]
• Baseline data: [Prior PFTs or baseline PaCO2 if relevant to oxygen or ventilation strategy]
• Current respiratory orders: [Active orders reviewed]
• Unavailable: [Expected diagnostic not available and reason] (Include only if a key diagnostic is expected but unavailable.)

Assessment

(Provide problem-oriented clinical impression ordered by severity.)

[Primary respiratory problem]

[Supporting evidence from assessment; severity and trajectory; safety considerations or contraindications for RT therapies]

[Additional respiratory problem]

[Supporting evidence; severity and trajectory; relevant considerations] (Add problems as needed; omit if single problem.)

Protocol-driven care: [Protocol or pathway name]; [Eligibility criteria met]; [Scoring or classification]; [Initial therapy level] (Include when using protocol-driven care.)

Non-protocol rationale: [Provider-directed plan / contraindication / patient refusal] (Include when not using a protocol.)

Respiratory Care Plan

Goals: [Target SpO2 range with rationale if non-standard]; [Ventilation goals: acceptable PaCO2/pH if chronic hypercapnia]; [Secretion clearance goals]; [Lung expansion goals]

Oxygen therapy: [Device]; [Titration approach]; [Monitoring frequency]; [Weaning criteria]; [Escalation criteria]; [Humidification plan]

Bronchodilator/aerosol therapy: [Medication and dose]; [Delivery device]; [Frequency]; [PRN criteria]; [Reassessment triggers]; [Side effect monitoring]

Airway clearance: [Modality]; [Frequency]; [Suctioning approach: indication-based with preoxygenation strategy]; [Precautions]; [Discontinuation criteria] (Include when secretion retention or impaired cough present.)

Lung expansion: [Modality]; [Coaching plan]; [Coordination with mobilization and analgesia optimization] (Include when post-op risk, restrictive pattern, or atelectasis present. Note that IS is part of a multicomponent bundle.)

Artificial airway care: [Suctioning plan]; [Cuff pressure monitoring frequency]; [Humidification plan]; [Skin or stoma care coordination]; [Weaning or decannulation pathway status] (Include only if airway present.)

NIV/IMV management: [Assessment frequency]; [Lung-protective monitoring plan]; [Daily SBT readiness screening]; [Synchrony monitoring] (Include only if on ventilatory support.)

Education provided: [Topics covered]; [Learner: patient / caregiver]; [Teach-back or comprehension assessment]; [Barriers and mitigation]

Follow-up: [Timeframe for reassessment]; [Parameters to reassess]; [Escalation thresholds for provider notification or rapid response]

Communication and Coordination

• [Provider notifications with reason and timing]
• [Nursing coordination needs: positioning, mobilization, secretion management]
• [Infection control considerations for aerosol-generating procedures]
• [Patient refusal or inability to participate and mitigating actions] (Include only if applicable.)

Signature

RT signature: [Name, credentials, date/time]

Co-signature: [Supervising RT name, credentials, date/time] (Include only if required, e.g., student with preceptor.)

(Use specific, objective descriptors. Omit subsections that do not apply rather than documenting N/A. Use facility-approved abbreviations.)