Respiratory Therapy Progress Note (Inpatient)

Date/Time of Encounter: [Encounter date and time] (If unavailable, enter "Unavailable")

Author: [Name and credentials] (If unavailable, enter "Unavailable")

Location: [Unit / room / bed] (If unavailable, enter "Unavailable")

Reason for Encounter: [scheduled assessment / protocol reassessment / acute event / post-treatment evaluation / therapy delivery / other]

Interval Summary

(Omit this section entirely for task-based encounters with no interval change. Do not copy forward prior content.)

[Overall trajectory: improved / unchanged / worsening] with [brief supporting context including key events such as escalation or de-escalation of support, new respiratory concerns, or barriers to care since last RT note]

Current Assessment

Encounter Status: [patient seen / not seen: off unit / procedure / refusal / asleep without distress / other]

(If patient not seen, document reason above and proceed directly to Plan. Replace assessment content below with any immediate follow-up actions.)

Patient-Reported Status: [dyspnea level, comfort, device tolerance] (If unable to participate: [sedation / delirium / language barrier / cognitive status / other])

Objective Findings: [SpO2 and oxygen status; respiratory rate; work of breathing; breath sounds with location; cough strength and secretion characteristics as relevant]

Current Respiratory Support: (Include only the active modality)

• Oxygen Therapy: [device type] at [flow/FiO2]; Tolerance: [tolerated / issues]
• NIV: [interface], [IPAP/EPAP or CPAP, FiO2, backup rate if set]; Tolerance: [good / fair / poor]; Leak: [minimal / moderate / significant]
• Invasive Ventilation: [airway type/size]; [mode and key settings]; Measured: [exhaled VT, PIP, MAP, Ve]; Synchrony: [synchronous / asynchrony type]; Humidification: [HME / heated humidifier]

Safety Observations: (Include for NIV or ventilated patients)

[Interface/airway securement status; skin integrity at contact points; cuff pressure if measured; humidification adequacy; alarm appropriateness]

Therapies Delivered

(Document each intervention with indication, authorizing order or protocol, and observed response. Include pre/post objective data when available. If therapy was withheld, refused, or not indicated, document reason and mitigation.)

• [Therapy type]: [Indication]; [Order/protocol authority]; [Details: dose/device/technique/settings/duration]; Response: [pre values] → [post values], [tolerance]; Complications: [none / specify]
• [Additional therapy if performed]: [Indication]; [Order/protocol]; [Details]; Response: [pre] → [post]; Complications: [none / specify]

RT Assessment

(Provide concise synthesis anchored to observed data and protocol goals. Avoid introducing new medical diagnoses.)

[Synthesis addressing oxygenation relative to target, ventilation adequacy, airway clearance effectiveness, and interface/airway safety as applicable. State whether current therapies are effective / ineffective / limited by tolerance and overall level of concern.]

Plan

Targets: [SpO2 range and/or ventilation parameters; comfort/tolerance goals]

Therapy Actions: [For each active therapy: continue / adjust / discontinue with rationale]

De-escalation Criteria: IF [specific improvement thresholds], THEN [reduce support]

Escalation Criteria: IF [specific deterioration thresholds], THEN [action and who to notify]

Follow-Up: [Next RT reassessment timing; pending orders and interim measures]