Medical Records & Patient Assessment

Role of RT & Modern Healthcare

  • RTs integral in diagnosis, treatment, follow-up
  • Care must promote health & prevent disease
  • Emphasis on right care/right time; avoid unnecessary interventions

Evidence-Based Practice (EBP)

  • Integrates research evidence, clinical expertise, patient values
  • Produces better outcomes & lower costs; structured decision making
  • Guides diagnostic accuracy, prognosis prediction, treatment choice
  • Key sources: peer-reviewed studies, systematic reviews, expert guidelines; databases (PubMed, CINAHL, Cochrane, etc.)

Critical Thinking Skills

  • Interpretation, analysis, data evaluation, inference, explanation
  • Inputs: chart, history, diagnostics, disease knowledge

Medical Records

  • Central, legal documentation; if not charted, it didn’t happen
  • Forms: EMR (single org), EHR (multi-org), paper chart
  • Chart review = first step for care planning & reimbursement

Chart Review Focus

  • Admitting diagnosis/history & MD orders
  • Respiratory status & care orders (O₂, vent, BiPAP, nitric)
  • Medications, labs, imaging, diagnostics
  • Isolation status; DNR/DNI; critical monitoring (cardiac, hemodynamic, ICP, respiratory)

Isolation Precautions

  • Standard: gloves (all patients)
  • Contact: gown + gloves (C. difficile, MRSA, Pseudomonas)
  • Droplet: gloves, surgical mask, eye protection (influenza, pertussis)
  • Airborne: N95, gloves, eye protection, gown (TB, measles, varicella)

Advanced Directives

  • DNR: no CPR | DNI: no intubation (non-invasive ok)
  • May be DNR only, DNI only, or both; always verify
  • Living Will: desired treatments; no surrogate appointment
  • Durable Power of Attorney for Health Care: appoints decision maker when patient incapacitated

Health Determinants

  • Genetics, access to care, environment, behaviors (smoking, obesity, inactivity, diet, substance use)

Smoking History

  • Pack-years = (packs/day)×(years smoked)=\,(\text{packs/day})\times(\text{years smoked})

Patient Education

  • Goal: behavior change to improve disease
  • Match method to learning style (visual, auditory, hands-on, lecture, discussion)

Four Critical Life Functions

  1. Ventilation – move air; assess RR, VTV_T, chest motion, breath sounds
  2. Oxygenation – get O<em>2O<em>2 into blood; assess HR, color, sensorium, SpO</em>2/PaO2SpO</em>2/PaO_2
  3. Circulation – move blood; assess HR, pulse strength
  4. Perfusion – deliver blood to tissues; assess BP, sensorium, temp, urine output

Emergency Priorities

  1. Ventilation (airway, breathing)
  2. Oxygenation (increase FiO2FiO_2)
  3. Circulation (compressions, defib, ACLS drugs)
  4. Perfusion (raise BP)
  • Most common issue: oxygenation
  • CODE BLUE when no breathing, pulse, or BP; confirm DNR/DNI status

Normal Adult Values

  • HR 60–100 bpm60\text{–}100\,\text{bpm} | RR 10–20 breaths/min10\text{–}20\,\text{breaths/min}
  • BP 120/80 mmHg  (90–140/60–90)120/80\,\text{mmHg}\;(90\text{–}140/60\text{–}90)
  • SaO2SaO_2 95–100%95\text{–}100\%
  • ABG: pH 7.35–7.45pH\,7.35\text{–}7.45 | PaCO<em>2 35–45 mmHgPaCO<em>2\,35\text{–}45\,\text{mmHg} | HCO</em>3− 22–26 mEq/LHCO</em>3^-\,22\text{–}26\,\text{mEq/L} | PaO2 80–100 torrPaO_2\,80\text{–}100\,\text{torr} | BE ±2 mEq/LBE\,\pm2\,\text{mEq/L}

Complete Patient Assessment

  • History: interview & chart; symptoms, perceptions, past history, risk factors (smoking, alcohol, drugs, weight, fitness, nutrition, occupation, environment, family)
  • Physical exam techniques: inspection, auscultation, palpation, percussion

Key Open-Ended Interview Areas

  • Cough: frequency, timing, duration
  • Sputum: amount, color, consistency
  • Chest tightness, wheeze, dyspnea (rest/exertion)
  • Current meds & therapies (O₂, devices)
  • Pulmonary history (asthma, COPD, CF, TB, etc.)
  • Smoking details; cessation status
  • Occupational/military/hobby exposures
  • Prior intubation/ventilation
  • Family respiratory history