Tracheostomy Care Note (Acute Care)

Date/Time: [Date and time of encounter]

Author: [Name], [Role/Discipline], [Service]

Location: [Unit/Bed or Care Area]

Reason for Note: [routine trach care / cuff check / inner cannula change / secretion management / speaking valve trial / weaning update / skin concern / other] (Select all that apply.)

Airway Status

• Trach Tube: [size], [cuffed / cuffless], [manufacturer/model], [date placed or postoperative day]. (Verify by direct inspection. If details cannot be confirmed, write "not verified" and include plan to confirm; do not infer from prior notes.)
• Current Interface: [ventilator / trach collar / heated aerosol / HME / speaking valve / capped] (Include relevant settings if applicable.)
• Cuff Status: [inflated / deflated]; cuff pressure [__ cmH₂O]; [within target / above target / below target]; [no adjustment / air added / air removed]. (If cuff pressure not checked, state reason.)
• Position & Security: [midline and stable / malposition suspected]; [securement condition]; flange [seated appropriately / not seated].
• Emergency Equipment: [Spare tubes and functional suction confirmed at bedside / deficiency noted—describe mitigation and escalation]

Assessment

• Respiratory: SpO₂ [__%] on [O₂ method/settings]; RR [__]; work of breathing [normal / mildly increased / moderately increased / labored]; breath sounds [description]. (If ventilated, include: mode, tidal volume or pressure level, PEEP, FiO₂, set rate.)
• Stoma & Skin: [intact / erythema / maceration / breakdown]; drainage [none / serous / purulent / bloody]; granulation tissue [present / absent]; bleeding [none / present]; [pressure points if noted]. (If device-related pressure injury present, stage and document escalation.)
• Dressing: [type]; [dry and intact / soiled / saturated]; [changed today / not changed]
• Secretions: [scant / moderate / copious]; [thin / thick / tenacious]; [color/character]
• Tolerance: [patient comfort, distress, or pain assessment]. (If nonverbal or sedated, document observed signs and note inability to obtain subjective report.)

Care Provided

(Include only interventions performed during this encounter. Omit categories not performed.)

• Suctioning: Indication: [visible secretions / coarse breath sounds / desaturation / patient request / other]; technique [closed / open]; route [tracheal / oral / both]; [saline instilled / no saline]; secretions [amount and character]; patient response [tolerated well / required recovery time / adverse response]
• Inner Cannula: [replaced / cleaned]; condition on removal [patent / mucus-coated / obstructed]; patency confirmed after care
• Site Care: [stoma cleaned]; [dressing changed]; [ties changed with two-person assist]
• Humidification: [heated humidification / HME / trach collar]; [adequate / inadequate—describe change made]
• Speaking Valve Trial: Cuff [confirmed fully deflated prior to placement / unable to deflate—trial not attempted]; valve [type]; duration [__ minutes]; SpO₂ [__%]; work of breathing [description]; air trapping [none / present]; voice quality [description]; outcome [tolerated / discontinued early—reason]. (Do not infer swallow safety from voice; SLP evaluation required.)

Plan

• Summary: [Current airway device, interface/mode, cuff status, and stoma condition in 1–2 sentences]
• Weaning/Decannulation: [on pathway—current stage / not on pathway / status unknown]; [today's progress or barriers]; [next step and responsible service]
• Concerns/Escalation: [bleeding / suspected displacement / plugging / failed trial / elevated cuff pressure requirements / none]. (If present: describe timeline, actions taken, and notifications.)
• Follow-up: [next assessment timing]; [pending consults or coordination needs]

Electronic Signature: [Name], [Credentials], [Date/Time]