Assessment and Planning

Respiratory Therapists shall assess all referred patients prior to the initiation of treatment, understand the objective of the procedure and clarify with the physician if necessary. Respiratory Therapists shall provide a written treatment plan outlining modality of therapy and probable frequency of assessments as per patient classification protocol.

Characteristics

Therapists will understand the term "assess" to mean the following factors are evaluated.

1. A patient diagnosis and treatment objective which specifically relates to the prescribed therapy:

• Any concurrent treatments and/or tests being applied to the patient which could influence the effect of the proposed treatment.
• Any pertinent information concerning the patient's occupation, life style, and/or home environment.

2. Relevant Objective Findings:

Objective findings are those facts which have been obtained as a result of specific tests. Examples include:

• laboratory results
• X-ray results
• arterial blood gases
• pulmonary function test

3. Relevant Subjective Findings:

Subjective findings are those impressions which have been obtained as a results of physical assessment and discussion with the patient. Examples of such finds include:

• shape of chest
• color
• respiratory rate
• clubbing
• auscultation

4. Treatment Planning

If the treatment plan does not correspond to the initial orders provided by the referring physician there will be a notation in the progress notes indicating any deviation in treatment has been discussed, and approved by, the referring physician.

5. Adverse Reactions

Any adverse reactions are communicated to the physician and other appropriate members of the Health Care Team.

ASSESSMENT

1. The history is complete:

CRITERIA:

The information recorded within the history will be pertinent, concise, and legible. The following will be recorded:

• Illness and/or surgery
• Previous hospitalization for the diagnosis and/or treatment
• Any medications currently being taken by the patient
• Any concurrent treatments and/or tests being applied to the patient which could influence the effect of the proposed treatment.
• Any pertinent information concerning the patient's occupation, lifestyle and/or home environment.

2. Objective assessment findings are evaluated:

CRITERIA:

The findings or results obtained as a result of an objective assessment techniques.

• Laboratory findings - i.e. polycythemia
• X-ray results - consistent with pneumonia
• Arterial blood gases - i.e. Acid/base status
• Pulmonary function tests - i.e. consistent with obstructive lung disease.

3. Subjective assessment findings are evaluated:

CRITERIA:

The findings or results obtained as a result of subjective assessment techniques:

• Observation of the patient's general physical appearance.
• Auscultation of the chest.
• Respiratory rate.
• Shape of chest.
• Color of skin.

4. Therapists will understand the phrase "written treatment plan" to mean that the following factors are recorded:

• Date, time, respiratory diagnosis
• Goals or objectives of the therapy
• Effects of the therapy
• Method or modality of the therapy
• Statement as to the frequency of follow-up assessments as per the patient classification guidelines.
• Any adverse reaction