STANDARD VII

Documentation

Respiratory Therapists will document initial assessments and patient response to therapy in the patient care record. Respiratory Therapists will document all pertinent information by exception to normal protocol on the patient care record.

Characteristics:

Therapists will understand the term "document in the medical record" to mean:

  1. The respiratory therapy assessment is legible, concise and complete.
  2. The initial physician's order is signed off by the therapist initiating treatment.
  3. Therapists accepting verbal orders will ensure that such orders are written in the medical record.
  4. Abbreviations used in charting will be in keeping with the acceptable hospital abbreviation list.
  5. Additional charting is done by exception, i.e. any course of action differing from hospital/departmental protocol is documented.
  6. Changes to therapy and/or requested order changes are noted on the chart.

Criteria:

Assessment documentation will include:

  1. Date and Time: Year/Month/Day/Time
  2. Respiratory diagnosis
  3. Type of therapy
  4. Objective of therapy
  5. Effect of therapy
  6. Adverse reactions
  7. Instructions given to patient or patient's family
  8. Therapist's full signature

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