Respiratory Therapy Assessment Report

---
name: respiratory-therapy-assessment-report
description: |
  Assess patients with acute and chronic breathing disorders and write a defensible findings report as a respiratory therapist.
  TRIGGERS - Use when a respiratory therapist needs a assessment & findings report for patients with acute and chronic breathing disorders in hospital wards, intensive care and clinics.
category: Respiratory Therapy
license: MIT
version: 1.0
---
# Assessment & Findings Report — Respiratory Therapy

Assess patients with acute and chronic breathing disorders and write a defensible findings report as a respiratory therapist. The deliverable is a structured assessment report with findings, evidence and recommendations.
This skill is written for a respiratory therapist working with patients with acute and chronic breathing disorders in hospital wards, intensive care and clinics.

## When to use
- You are a respiratory therapist preparing, delivering or reviewing this part of your work in hospital wards, intensive care and clinics.
- You need a defensible, repeatable approach that produces a structured assessment report with findings, evidence and recommendations.
- A colleague, auditor or client asks how this was done and what evidence supports it.

## Key Concepts
| Term | Meaning |
|------|---------|
| Blood gas | a blood test measuring oxygen, carbon dioxide and acidity |
| Extubation | removing a breathing tube |
| Oxygen saturation | the percentage of haemoglobin carrying oxygen |

## Workflow
1. **Step 1** - Review the intake record and ventilation charts so the assessment builds on verified information, not assumptions
2. **Step 2** - Carry out the assessment using ventilators, following the recognised method for hospital wards, intensive care and clinics
3. **Step 3** - Compare findings against the benchmarks behind blood gas turnaround and note where evidence is strong, weak or missing
4. **Step 4** - Draft the report: findings first, then interpretation, then recommendations in priority order
5. **Step 5** - Check the draft for accuracy and for ventilator alarms ignored; have it reviewed where the profession's standards require a second sign-off

## Profession-Specific Components
| Component | Details for Respiratory Therapy |
|-----------|-------------------------------|
| Core documentation | ventilation charts; oxygen therapy records; lung function results; weaning plans |
| Core tools & equipment | ventilators; oxygen delivery devices; blood gas analysers; nebulisers |
| People involved | patients with acute and chronic breathing disorders; the respiratory therapist; colleagues and other services in hospital wards, intensive care and clinics |
| Primary record | ventilation charts — keep it current, dated and attributable |

## Output Format
**Context:** [Situation in hospital wards, intensive care and clinics] | **Objective:** [What this must achieve] | **Audience:** [patients with acute and chronic breathing disorders and other stakeholders]

The finished output is a structured assessment report with findings, evidence and recommendations, structured as:
1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

### Action Plan
1. **Immediate:** Confirm scope, consent and the evidence available in ventilation charts.
2. **Short-term:** Complete the workflow steps and record outcomes against blood gas turnaround.
3. **Medium-term:** Review results, close actions, and update local procedures in hospital wards, intensive care and clinics.

## Success Metrics
| Metric | Target | Method |
|--------|--------|--------|
| blood gas turnaround | Agree a local target and track the trend | Measured from ventilation charts and reviewed on a set cycle |
| weaning success rates | Agree a local target and track the trend | Measured from ventilation charts and reviewed on a set cycle |
| oxygen target compliance | Agree a local target and track the trend | Measured from ventilation charts and reviewed on a set cycle |
| extubation outcomes | Agree a local target and track the trend | Measured from ventilation charts and reviewed on a set cycle |

## Guardrails & Quality Checks
- Never let this happen: ventilator alarms ignored.
- Never let this happen: incorrect oxygen targets.
- Never let this happen: tube displacement unnoticed.
- Work only within the competence and authority of a respiratory therapist; escalate or refer anything beyond it.
- Record facts and observations, not speculation, and keep records confidential to hospital wards, intensive care and clinics's rules.
- Verify names, dates, figures and measurements twice before anything is issued or signed off.
- Use only real, verified information from the case in hand — never invent results, credentials or evidence.

## Example (illustrative)
A respiratory therapist in hospital wards, intensive care and clinics applies this workflow for patients with acute and chronic breathing disorders: they open
ventilation charts, work through the five steps using ventilators, and close by recording
the outcome against blood gas turnaround and agreeing the next review date. (Illustrative example only —
replace with the real details of the case in hand.)