Ventilator Check Note (Mechanical Ventilation)

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

Author/Credentials: [Name and role/credentials]

Unit/Bed: [Unit and bed]

Ventilator ID: [Device label or number]

Context: [routine check / post-change / event response]

Indication & Targets

[Primary indication for invasive mechanical ventilation; ordered physiologic targets including SpO₂ range, PaCO₂ goal, and any active protocols, or "targets not available"] (Keep to one concise line; may remain consistent across checks unless changed.)

Airway, Settings & Safety

• Airway: [ETT / tracheostomy] — [size] — [depth/marking or stoma status] — Cuff pressure: [value or "not assessed" with reason]
• Ventilator mode: [Mode name]
• Set parameters: [FiO₂, PEEP, rate, tidal volume with mL/kg PBW if available, pressure support or inspiratory pressure as applicable] (If PBW unavailable, document reason and plan to obtain height.)
• Trigger/Cycle: [Trigger sensitivity and cycling criteria] (Only include if asynchrony present or recent changes made.)
• Alarms: [Alarm limits verified]; [Clinically meaningful alarm events or "none"]
• Humidification & circuit: [Humidification type]; [Circuit integrity confirmed]; [Condensate managed] (Note any issues and corrective actions.)

Patient Response & Tolerance

• Measured parameters: [Total RR, spontaneous RR, exhaled Vt, minute ventilation, PIP, MAP if used, SpO₂, EtCO₂ if monitored]
• Static measurements: [Plateau pressure; driving pressure] (Include only if obtained via inspiratory hold during this assessment; do not infer or record as normal without measurement.)
• Tolerance: [comfortable / mild distress / moderate distress / severe distress]; [Observed work of breathing indicators]
• Synchrony: [synchronous / asynchrony present] — [If asynchrony: type, severity, clinical impact] (If waveform assessment not possible, document reason.)
• Sedation context: [Sedation/paralysis status and scale if available] (Only include if relevant to interpretation.)

Interventions & Changes

(Omit this entire section if no interventions were performed and no ventilator setting changes were made.)

• Interventions: [Procedure type: suctioning, aerosol therapy, recruitment, etc.]; [Indication]; [Method]; [Patient response and relevant findings] (Include for each intervention performed.)
• Setting changes: [Parameter: before → after]; Rationale: [Physiologic/safety goal]; Authorization: [Per provider order (name/role) / per RT-driven protocol (protocol name)]; Immediate response: [Observed effect] (If order uncertain, document provider communication rather than implying authorization.)

Assessment & Plan

• Assessment: [Oxygenation status with supporting evidence]; [Ventilation status with supporting evidence]; [Lung-protective alignment: Vt mL/kg PBW, Pplat and driving pressure if measured]; [Mechanics/synchrony concerns or "no concerns"]
• Plan: [Next reassessment time]; [Specific monitoring actions]; [Weaning/liberation status if applicable]; [Escalation/notification triggers]; [Provider/nursing communication and pending tasks] (Include at least one objective follow-up statement even if stable.)