How to Document Respiratory Therapy Sessions and Patient Assessments

A practical guide for respiratory therapists on documenting therapy sessions, patient assessments, ventilator management, and pulmonary rehabilitation using compliant SOAP note structures.

Respiratory therapists document more frequently than nearly any other allied health profession. In an ICU, an RRT may touch the same patient four or five times in a single shift, each contact generating its own required record. In outpatient pulmonary rehabilitation, a session note must capture exercise tolerance, oximetry trends, and patient education within minutes of finishing.

What makes respiratory therapy documentation distinctive is the clinical density. A single SOAP note may need to capture breath sounds, arterial blood gas (ABG) values, ventilator settings, patient response to treatment, and a plan that spans the next several contacts. Doing this well, consistently, and without burning two hours per shift is the practical challenge this guide addresses.

Why Respiratory Therapy Documentation Matters Beyond Compliance

Documentation in respiratory care is not simply a billing function. It is the communication mechanism between you and every other provider touching that patient.

When a night-shift RT inherits a vented patient, the prior note tells them whether the last weaning attempt was interrupted by tachypnea or by a physician override. When a pulmonologist reviews outpatient rehab progress, the trend data in your notes informs medication adjustments. When Medicare reviews a claim for therapeutic procedure code 94640, your note is the clinical justification.

Poor documentation creates real clinical risk. An undocumented adverse event during bronchial hygiene therapy leaves no record for a follow-up provider. A ventilator weaning plan that exists only in the shift handoff conversation leaves the next clinician without context.

The SOAP Format Applied to Respiratory Care

Most acute care hospitals use SOAP notes (Subjective, Objective, Assessment, Plan) for respiratory therapy encounters. Some facilities use a condensed format or problem-oriented charting, but SOAP remains the most transferable structure across settings.

Subjective

This section captures what the patient reports. For respiratory care, relevant subjective data includes:

Chief complaint as stated by the patient ("I feel like I can't get a deep breath")
Dyspnea rating using a validated scale such as the Modified Borg Dyspnea Scale (0-10) or the Medical Research Council (MRC) Dyspnea Scale
Changes in sputum production, color, or consistency
Exercise tolerance changes reported since last contact
Pain with breathing or coughing

For intubated or non-verbal patients, document the absence of subjective data explicitly. "Patient intubated and sedated. Subjective data not obtainable" is more defensible than a blank section.

Objective

The objective section is the core of most respiratory therapy notes. It should include all measurable clinical findings at the time of the encounter.

Vital signs: Heart rate, respiratory rate, blood pressure, temperature, and SpO2 (oxygen saturation) on current delivery device and FiO2 setting.

Breath sounds: Document by lobe. Not "diminished bilaterally" but "diminished in left lower lobe with scattered rhonchi in right middle lobe." Specificity here supports medical necessity and flags deterioration when compared across notes.

ABG results (when obtained): Report all six values: pH, PaCO2, PaO2, HCO3, base excess or deficit, and SaO2. Include the FiO2 at time of draw and the P/F ratio (PaO2 divided by FiO2) for mechanically ventilated patients.

Current oxygen delivery or ventilator settings: For spontaneously breathing patients, document the device (nasal cannula, simple mask, non-rebreather, high-flow nasal cannula), flow rate, and FiO2. For ventilated patients, document the full mode and settings.

Ventilator parameters (if applicable):

Mode (AC/VC, AC/PC, SIMV, CPAP/PSV, APRV)
Tidal volume (set and delivered)
Respiratory rate (set and total)
PEEP
FiO2
Peak inspiratory pressure (PIP)
Plateau pressure (Pplat) if measured
I:E ratio
SpO2 trend over the shift (not just the spot value)

Treatment performed: The specific procedure, duration, and any adjuncts used. For example: "Incentive spirometry instruction completed, patient achieved 1,200 mL on 8 of 10 attempts. Bronchodilator therapy administered via SVN with 2.5 mg albuterol in 3 mL NS over 12 minutes."

Assessment

This is where your clinical reasoning lives. The assessment synthesizes the objective data into a clinical interpretation.

For a spontaneously breathing patient, this might read: "Mild persistent hypoxemia (SpO2 87% on 2 L/min NC) with improvement following bronchodilator therapy (SpO2 94% post-treatment). Breath sounds improved, rhonchi clearing in right lower lobe. Clinical picture consistent with mild acute exacerbation of COPD."

For a ventilated patient: "Patient demonstrating spontaneous respiratory effort above set rate (total rate 22, set rate 14). ABG from 0800 shows pH 7.38, PaCO2 44, PaO2 82 on FiO2 0.40 with P/F ratio of 205. Adequate oxygenation. Consider readiness for spontaneous breathing trial."

Plan

The plan section should be specific enough that a different RT can execute it without hunting down the ordering provider. Include:

Next scheduled treatment and timing
Parameters to watch and thresholds for escalation
Pending physician orders (e.g., "Will request repeat ABG in 4 hours if SpO2 drops below 92%")
Weaning plan if applicable
Education provided or planned

Documenting ABG Interpretation

ABG results appear frequently in respiratory therapy notes, and vague documentation creates compliance gaps. The standard is to document the raw values, your interpretation, and the clinical action taken.

Fictional example: Sofía L. is a 58-year-old woman admitted for acute hypercapnic respiratory failure in the setting of severe COPD. Her 0600 ABG on HFNC at 40 L/min and FiO2 0.45:

pH: 7.28
PaCO2: 68
PaO2: 74
HCO3: 31
BE: +4
SaO2: 93%
P/F ratio: 164

A complete documentation entry would include: the raw values, the interpretation ("Partially compensated respiratory acidosis with moderate hypoxemia. Chronic component suggested by elevated HCO3 and positive base excess. Acute-on-chronic pattern."), and the action taken ("Notified Dr. Martinez at 0618. Orders received to initiate BiPAP at IPAP 12/EPAP 5, FiO2 0.45. Patient placed on BiPAP 0630. Tolerated initiation without agitation.").

Document the name of the physician notified and the time of notification in every critical value communication.

Mechanical Ventilator Management Documentation

Ventilator management notes carry more legal and clinical weight than almost any other respiratory therapy record. They are reviewed during adverse event investigations, audits, and malpractice proceedings.

The essential elements for every ventilator check are:

Current mode and all parameters (listed above)
Delivered versus set values (particularly when they diverge)
Alarm settings (high pressure, low minute volume, apnea)
Patient synchrony assessment (fighting the vent, dyssynchrony patterns)
Sedation level if relevant to ventilator management (RASS score)
Trending of Pplat and driving pressure when lung-protective ventilation is the goal
Any mode or parameter changes made and the clinical rationale

Fictional example: Rafael M. is a 44-year-old male intubated for ARDS following aspiration pneumonia. ICU day 3. The RT note for the 1400 ventilator check documents:

"Mode: AC/VC. VT set 380 mL (6 mL/kg IBW 63 kg). Rate: 22. PEEP: 10. FiO2: 0.55. PIP: 32. Pplat: 27 (measured via 0.5-second inspiratory hold). Driving pressure: 17 cmH2O. Total rate: 22 (no patient effort above set rate). SpO2: 94%. RASS: -2. Ventilator synchrony intact. ABG from 1200: pH 7.35, PaCO2 48, PaO2 76, P/F ratio 138. Lung-protective ventilation maintained. FiO2 stable from prior check. Dr. Nguyen updated at 1415 regarding driving pressure trend. No parameter changes at this time."

Note the driving pressure documentation and the rationale for no changes. These two elements are frequently missing from ventilator notes and create audit vulnerabilities.

Oxygen Therapy Documentation

Oxygen therapy documentation seems straightforward but generates frequent compliance denials. The key elements are the clinical indication, the delivery device with flow rate and FiO2, the patient's SpO2 before and after initiation or adjustment, and the therapeutic goal.

CMS requires that supplemental oxygen for Medicare beneficiaries be supported by specific documentation of hypoxemia. For home oxygen orders, the qualifying SpO2 threshold is 88% or below, or an arterial PaO2 of 55 mmHg or below, documented during a qualifying test (resting, ambulatory, or nocturnal). Document the conditions of the test explicitly.

For acute care, document the indication clearly rather than using shorthand. "O2 to maintain SpO2 greater than or equal to 92% per physician order for acute hypoxemia in the setting of community-acquired pneumonia" is better than "O2 for low sats."

Pulmonary Rehabilitation Session Notes

Outpatient pulmonary rehabilitation notes differ meaningfully from acute care documentation. The emphasis shifts toward exercise prescription data, functional outcomes, and patient education, while still capturing the respiratory monitoring that makes PR distinct from generic cardiac rehab.

A standard pulmonary rehab session note should include:

Pre-session assessment: SpO2 on current baseline oxygen (or room air), resting heart rate, resting dyspnea rating (Borg scale), blood pressure, any new symptoms since last session.

Exercise component documentation: For each exercise station or modality, document the mode (treadmill, cycle ergometer, resistance training, upper extremity ergometry), intensity parameters (speed, grade, wattage, resistance level), duration, patient's peak SpO2 during exercise, peak heart rate, and Borg dyspnea rating at peak exertion. Document any desaturation events and interventions.

The six-minute walk test (6MWT) is the most common functional outcome measure in pulmonary rehabilitation. When documenting a 6MWT, include: total distance walked, stopping reasons if applicable, baseline and nadir SpO2 with the FiO2 at time of test, supplemental oxygen flow required during the test, and Borg dyspnea rating at the end. Compare to the prior 6MWT result when available.

Education component: Topic covered, format (verbal, printed material, demonstration), and patient's demonstrated understanding or return demonstration. Generic entries like "education provided" without content are insufficient for CMS review.

Post-session assessment: Final SpO2, heart rate, dyspnea rating, and any adverse events.

Fictional example: Elena V. is a 67-year-old woman with severe COPD (FEV1 38% predicted) in session 14 of 36. Pre-session SpO2 is 91% on 2 L/min NC. During cycle ergometer training at 45 watts for 12 minutes, nadir SpO2 was 87% with supplemental oxygen titrated to 4 L/min to maintain SpO2 above 90%. Peak Borg: 5. The RT documents the oxygen titration and the SpO2 response, notes that Elena completed her 12-minute target without stopping, and records the patient education topic for the session (pursed-lip breathing technique with return demonstration completed successfully).

CMS Compliance Considerations for Respiratory Services

Medicare and Medicaid review respiratory therapy claims using specific documentation criteria. The most frequent audit findings in respiratory care involve:

Medical necessity: Every billable respiratory therapy service requires documented evidence that the treatment was clinically indicated and not simply routine. "Per protocol" without clinical justification does not satisfy medical necessity language on its own.

Procedure-specific documentation: CPT codes for respiratory services (94640, 94664, 94770, 94002-94004, 94005) each have documentation requirements tied to their definitions. Code 94640 (small volume nebulizer treatment) requires documentation of the drug, dose, diluent, delivery time, and patient response. Code 94664 (demonstration and evaluation of inhalation device) requires documentation of the technique instruction and patient demonstration of competence.

Physician order: Respiratory therapy services require a signed physician order. Document the order in your note, including the authorizing physician name and order date.

Time-based codes: For time-based ventilator management codes (94002-94004), document the total face-to-face time, not just the procedure time. The time documentation must support the code billed.

Common Respiratory Therapy Documentation Errors

Copying the prior note without updating. "Copy forward" or "clone" errors generate identical notes across multiple chart encounters, which is both an audit red flag and a patient safety hazard. Every note must reflect the encounter on that date, not the prior shift.

Vague breath sound documentation. "Coarse breath sounds" throughout does not capture clinical change. Specify the anatomic location, character, and any change from prior.

Missing the pre/post comparison for bronchodilator therapy. Documenting that you gave albuterol without documenting the patient's response (SpO2, breath sounds, heart rate, dyspnea rating before and after) misses the clinical rationale that supports the billing.

Undocumented critical value notifications. When an ABG or SpO2 result triggers a clinical response, the notification to the ordering provider must be in the note with the name, time, and response.

Incomplete ventilator weaning documentation. If a spontaneous breathing trial was attempted and failed, document why. "Patient failed SBT" without the failure criteria leaves the next RT and the physician without a clinical picture.

Omitting the FiO2 from SpO2 values. An SpO2 of 96% on room air and an SpO2 of 96% on 60% FiO2 are clinically very different. The delivery device and FiO2 must accompany every SpO2 documentation.

Missing patient education content. Both acute care and outpatient respiratory notes frequently document that education occurred without specifying the topic, format, or patient's response. This creates gaps for billing review and follow-up planning.

Working Efficiently Across a High-Volume Shift

Respiratory therapists in acute care often document 20 or more patient contacts per shift. Efficiency is not optional. A few practices that reduce documentation time without reducing quality:

Use consistent templates by encounter type. A ventilator check has a predictable structure. A bronchodilator treatment has a different one. Having a pre-structured template for each encounter type means you fill in variable data rather than rebuilding the note from scratch each time.

Document in real time when possible. Notes written during or immediately after an encounter are more accurate and take less time than reconstructed notes at the end of a shift. For bedside contacts, a brief field note at the bedside can anchor the formal note written minutes later.

Separate monitoring from treatment. Ventilator checks and patient assessments are distinct documentation events. When they occur together, label them clearly so the record shows both were completed.

Tools like NotuDocs let you preload note templates for recurring encounter types (ventilator checks, bronchodilator treatments, pulmonary rehab sessions) so the structure is waiting for you and AI fills the sections from your raw notes. This works particularly well for high-volume RT workflows where the note structure is consistent but the clinical values change with every encounter.

Documentation Checklist for Respiratory Therapy

Every Acute Care Encounter

Patient identification and encounter date/time documented
Subjective data (or explicit notation that patient cannot provide it)
Vital signs with SpO2 including delivery device and FiO2
Breath sounds by location with characterization
Treatment performed with drug, dose, device, duration where applicable
Pre- and post-treatment comparison documented
Clinical interpretation in assessment section
Plan specific enough for any qualified RT to execute

ABG Documentation

All six ABG values recorded
FiO2 at time of draw documented
P/F ratio calculated and recorded for vented patients
Interpretation stated explicitly
Physician notification with name, time, and response documented

Ventilator Management Notes

Full mode and all parameters documented
Delivered versus set values noted when they diverge
Plateau pressure and driving pressure included when lung-protective protocol is active
Patient synchrony and sedation level addressed
Any changes documented with clinical rationale
No copy-forward from prior note without updated clinical data