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Section Navigation Part 1 of 26 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. 7. Mode B — guided documentation prompts 10. Subjective — ask 11. Objective — observe 12. Measure 13. 8. Interventions performed 14. 9. Patient and caregiver teaching 15. 10. Response and reassessment 16. 11. Physician or provider notification 17. 12. Red flags and emergency escalation 18. 13. Skilled-need justification 19. 14. Medical-necessity statement 20. 15. Homebound relevance 21. 16. Weak vs. strong documentation 22. 17. Common audit and denial risks 23. Smart phrases 24. Normal narrative bank — stable / at-baseline 25. Abnormal narrative bank — focused / at-risk 26. 19. Sources and clinical references Previous Next General Section SKILLED DOCUMENTATION GUIDELINES — EXPANDED
DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Body System Reference · 2.1
Respiratory / Pulmonary
Lungs, airway, oxygenation, and ventilation. Diagnoses commonly routed here: COPD, asthma, pneumonia, and heart failure with pulmonary congestion.
Module code
SYS-RESPIRATORY
Version
1.0 · Population: Adult · Authoring level: DiraChart
Used alongside
Vital Signs (Core Domain) · Cardiovascular (Body System) · Disease overlays: COPD, CHF · Foundations apply to every visit.
How to use this module
This module supplies the complete respiratory examination and the skilled language that proves it required a licensed nurse. Each narrative is a structured example to be edited to reflect what was actually assessed and the patient's specific orders — not a phrase to copy verbatim. Disease overlays (COPD, and heart failure with pulmonary congestion) add diagnosis-specific monitoring on top of this page and do not repeat the examination. The universal writing rules in Foundations apply to every visit and are not reprinted here.
Section Navigation Part 1 of 26 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. 7. Mode B — guided documentation prompts 10. Subjective — ask 11. Objective — observe 12. Measure 13. 8. Interventions performed 14. 9. Patient and caregiver teaching 15. 10. Response and reassessment 16. 11. Physician or provider notification 17. 12. Red flags and emergency escalation 18. 13. Skilled-need justification 19. 14. Medical-necessity statement 20. 15. Homebound relevance 21. 16. Weak vs. strong documentation 22. 17. Common audit and denial risks 23. Smart phrases 24. Normal narrative bank — stable / at-baseline 25. Abnormal narrative bank — focused / at-risk 26. 19. Sources and clinical references Previous Next 