Clinical Documentation (assignments’ guidelines)

1. Ahmed Al Gahtani, BSRC, RRT
Associate Director Clinical Education
Chairman, RTS Advisory Committee
Dept. of Respiratory Therapy Program
Inaya Medical College, Riyadh
Saudi Society for Respiratory Care Executive Board of Directors, Member
CEO, SSRC
Clinical Respiratory Therapy / Practice
Clinical Assignments’ Guidelines

2. • This presentation covers all clinical courses:
▫ RTS 365 Clinical Respiratory Therapy / Practice (General Care)
▫ RTS 476 Clinical Respiratory Therapy / Practice (Adult ICU)
▫ RTS 485 Clinical Respiratory Therapy / Practice (Neonatal/Pediatrics ICU)
• Students should follow guidelines related to their assignments based on
their current clinical rotation

3. • RTS 365 Clinical Respiratory Therapy / Practice (General Care)
▫ 6 SOAP Notes
▫ 2 Case Reports
▫ 2 Handover Reports (ISBAR)
• RTS 476 Clinical Respiratory Therapy / Practice (Adult ICU)
▫ 6 SOAP Notes
▫ 2 Case Reports
▫ 2 Handover Reports (ISBAR)
▫ 1 Oral Case Presentation
• RTS 485 Clinical Respiratory Therapy / Practice (Neonatal/Pediatrics ICU)
▫ 6 SOAP Notes
▫ 2 Case Reports
▫ 2 Handover Reports (ISBAR)
▫ 1 Oral Case Presentation
Clinical Assignments

4. • Upon successful completion of these assignments student will be able
to:
▫ Assess & gather respiratory care clinical data & findings related to the
patient case.
▫ Arrange & formulate gathered data & findings in appropriate format as
SOAP, case report, handover report or case presentation.
▫ Communicate appropriately in an oral and written format.
Intended Learning Outcomes

5. 6 SOAP Notes

6. • Student should assess the patient & review patient’s file, then collect and
arrange needed data and findings, in hand writing with patient info and area.
(this for student use & reference, not to submit unless asked to show your
work by instructor)
• Type your SOAP, save it as PDF. (no patient name or MRN)
• SOAP notes are due by the end of your last clinical rotation day.
• SOAP notes to be submitted via email (college email)
• Email title should be as follow “Clinic level (course code number)– Clinical Site
– SOAP Assignment” example “Clinic One (RTS365) – KSUMC – SOAP
Assignment”.
• Copying each other notes will not be tolerated. (will result in disciplinary
action)
SOAP Note Guidelines

7. SOAP Note
Subjective
• Information given by patient can tell you
about how he/she feels
• What is the patient’s level of consciousness?
• What is the patient’s chief complaint?
• How does the patient feel at the time of the
assessment?
• Can the patient contribute any information that
affects his/her diagnosis or treatment plan?
Objective
• Everything you see
• Vital signs
• Physical examination of the head and neck, abdomen,
and extremities for physical evidence of respiratory
abnormality
• Physical examination of the thorax (heart and lungs)
by inspection, palpation, percussion, and auscultation
• Review of clinical laboratory studies
• Review of radiological procedures: chest radiographs,
computed tomograms, and magnetic resonance
images
• Review of respiratory mechanics monitoring

8. SOAP Note
Assessment
• Nature and cause of patient’s problems
• Form a “problems list”
• Major types of problems: Airway management,
Ventilation, Oxygenation, Work of breathing &
Cardiopulmonary problems
Plan
• Indicate an intervention and therapeutic
objective. A good medical plan must
include a goal against which one can
measure
• The purpose of the treatment
• Responsiveness of the patient
• Objectives for knowing when to make decisions
• Objectives as end-point criteria for the termination of
the therapy

9. • Assessment, Plan, Implementation, and Evaluation (APIE) Charting
▫ A primary goal of the assessment, plan, implementation, and evaluation (APIE) method is
to condense the data-collection statements and emphasize evaluation of the
effectiveness of the interventions.
• Problem, Intervention, and Plan (PIP) Charting
▫ Minimalist approach
▫ PIP charting is based on the assumption that the data collection has already been done in
the medical record and that the subjective and objective information gathering of SOAP
charting is redundant.
▫ Under the “Problem” section, the patient’s problem is stated simply, often with reference
to the evidence that brought the author to this conclusion.
▫ The “Intervention” section, which describes what is being done for the patient.
▫ The “Plan” section shows how the intervention will be assessed or carried out,
depending on the intervention.
Other Documentation Methods

10. SOAP Note
Let’s Practice

12. 2 Case Report

13. • Student should assess the patient & review patient’s file, then collect and
arrange needed data and findings, in hand writing with patient info and area.
(this for student use & reference, not to submit unless asked to show your
work by instructor)
• Type your Case Report, save it as PDF. (no patient name or MRN)
• Case report notes are due by the end of your last clinical rotation day.
• Case report to be submitted via email (college email)
• Email title should be as follow “Clinic level (course code number)– Clinical Site
– Case Report Assignment” example “Clinic One (RTS365) – KSUMC – Case
Report 1 Assignment”.
• Copying each other reports will not be tolerated. (will result in disciplinary
action)
Case Report Guidelines

14. • The case report should be structured as following:
▫ Introduction:
 In this section you will describe your purpose of selecting the case, significant
of the case and/or the uniqueness of the case.
▫ Case Summary/Description:
 Identifying information/chief complaint
 History of the present illness
 Other active medical problems, medications, habits, and allergies
 Physical examination (key findings only)
 Investigations, clinical studies & tests
 Assessment and treatment plan
Case Report Guidelines

15. • The case report should be structured as following:
▫ Discussion:
 The discussion serves to summarize and interpret the key findings of the case report
 To derive new knowledge and applicability to practice, and to draw clinically useful
conclusions
▫ Conclusion:
 State the lessons/experiences that may be learnt from the case report, and how things
can be managed differently in a similar situation/case
▫ References:
 The references listed at the end of the case report should be carefully chosen by virtue
of their relevance.
 References should provide additional information for readers interested in more detail
than can be found in the case report
Case Report Guidelines cont.,

16. 2 ISBAR

17. • Student should assess the patient & review patient’s file, then collect and arrange
needed data and findings, in hand writing with patient info and area. (this for
student use & reference, not to submit unless asked to show your work by
instructor)
• Type your ISBAR, save it as PDF. (no patient name or MRN)
• ISBAR notes are due by the end of your last clinical rotation day.
• ISBAR to be submitted via email (college email)
• Email title should be as follow “Clinic level (course code number)– Clinical Site –
Case Report Assignment” example “Clinic One (RTS365) – KSUMC – ISBAR 1
Assignment”.
• Copying each other reports will not be tolerated. (will result in disciplinary action)
• In addition to that the student is required to receive and give handover to class
mates, preceptor or clinical instructor on daily bases using ISBAR method.
Case Report Guidelines

18. • Latest methodology for communication for over-the-phone reporting &
handover (endorsement) reporting.
▫ Introduction:
 Who are you, who is the patient and location (area)
▫ Situation:
 What is happening now? Chief complaint or acute change
▫ Background:
 What factors led to this event? Admitting diagnosis, history, vital signs, lab results, or
other pertinent clinical findings
▫ Assessment:
 What do you see? What do you think is going on?
▫ Recommendation (Request):
 What action(s) do you propose? What do you think should be done?
Therapist-Driven Protocol Program

20. 1 Oral Case Presentation

21. • Student should assess the patient & review patient’s file, then collect and arrange needed
data and findings, in hand writing with patient info and area. (this for student use &
reference, not to submit unless asked to show your work by instructor)
• The oral case presentation should be constructed as you are presenting the case for the first
time. Be ready to discuss the case with the audience
• After collecting the patient data, you should have the case in both written format (printed)
and be ready to present it oral format on the due date.
• Your written case should be saved as PDF. (no patient name or MRN)
• Case is due by the end of your last clinical rotation day.
• Case to be submitted via email (college email)
• Email title should be as follow “Clinic level (course code number)– Clinical Site – Written
Oral Case Assignment” example “Clinic One (RTS365) – KSUMC – Case Assignment”.
• Copying each other case will not be tolerated. (will result in disciplinary action)
• Oral case presentation duration is 12 to 15 mins.
Oral Case Presentation Guidelines

22. • The format includes the content areas usually included in an oral case presentation for a patient who
is newly admitted to the hospital or seen for the first time in the office.
• Case presentations on rounds in the hospital would generally be much shorter and include a brief
summary of the patient's history followed by new information obtained in the last 24 hours.
• The Case Format Must Include the Following:
▫ Introduction
▫ History of Present Illness (HPI)
▫ Past Medical History (PMH)
▫ Medications
▫ Allergies
▫ Social History (SOCIAL HX)
▫ Family History (FAM HX)/Maternal History
▫ Review of Systems (ROS)
▫ Physical Examination
▫ Diagnostic Data
▫ Assessment & Plan
Oral Case Presentation Guidelines

23. • Introduction
▫ The introduction sets the stage by briefly
summarizing:
 Who the patient is (age, gender, sometimes
major diseases or occupation)
 Why they came in (the chief complaint and/or
other health issues addressed at the visit)
 Brief time course (using either date of onset
or days prior to presentation)
 Source of the history and reliability (only
included if unable to obtain adequate history
from the patient)
Oral Case Presentation Guidelines
Mr. Ahmed is a 42-year-old man with
history of smoking, who was well until 2
days ago when he developed SOB with
marked increased WOB and fatigue. The
source of the history is the
patient, whose reliability is questionable
due to some confusion, and old hospital
records.

24. • History of Present Illness (HPI)
▫ Describe the chronological account of events since the onset of the problem.
▫ Provide significant details of symptoms, including symptom dimensions (PPQRST) as appropriate.
▫ Include pertinent positives and negatives only. This may include information from any portion of the history,
i.e., past medical or surgical history, medications, allergies, family or social history, and review of systems, that
may relate to the specific diagnostic hypotheses you are considering.
• Past Medical History (PMH)
▫ Chronic Diseases, Significant medical illnesses, Hospitalizations, Surgeries, Health Maintenance
• Medications
▫ List of the patient medications at home and medications started up on admission
• Allergies
▫ Any Known and documented allergies to medications or food
• Social History (SOCIAL HX)
▫ Type of work/profession (exposures)
▫ Habits (smoking or drug abuse)
▫ Area of residence (if relative to patient case)
Oral Case Presentation Guidelines

25. • Family History (FAM HX)/Maternal History
▫ Emphasis is placed on the identification of illnesses within the family (particularly
among first degree relatives) that are known to be genetically based and therefore
potentially heritable by the patient. This would include: coronary artery disease,
diabetes, certain cancers and autoimmune disorders, etc. If the family history is
non-contributory, it’s fine to say so.
• Review of Systems (ROS)
▫ Pertinent positive and negative findings discovered during a review of systems are
generally incorporated at the end of the HPI. The listener needs this information to
help them put the story in appropriate perspective. Any positive responses to a
more inclusive ROS that covers all of the other various organ systems are then
noted. If the ROS is completely negative, it is generally acceptable to simply state,
"ROS negative.”
Oral Case Presentation Guidelines

26. • Physical Assessment (examination)
▫ General appearance
▫ Vital signs
▫ For the rest of the examination, include pertinent positives (abnormal
findings) and negatives (normal findings that relate to the differential
diagnosis) only.
• Diagnostic Data
▫ Test results, usually laboratory and radiology
Oral Case Presentation Guidelines

27. • Assessment & Plan
▫ A differential diagnosis, that is, a list of possible diagnoses
▫ List of patient problems
▫ The assessment and plan typically concludes by mentioning appropriate
course of action as an interventions and/or prophylactic considerations
Oral Case Presentation Guidelines

28. • Wilkins' Clinical Assessment in Respiratory Care, Chapter 21, 7E.
• A Practical Guide to Clinical Medicine, Smith, pp. 227‐233 , at
http://meded.ucsd.edu/clinicalmed/oral.htm
References