The recurring failures (left), why each fails (center), and the corrected, defensible pattern (right). Weak and strong examples are combined here so reviewers see the transformation directly.
Weak — does not survive
Why it fails
Strong — defensible
“Lungs clear.”
No technique or fields, no oxygenation, and no statement of why a nurse was required.
“Skilled resp assessment: lungs CTA bilat all fields; RR 16 unlabored; SpO2 96% RA; no WOB; denies cough/dyspnea; stable. RN judgment applied to detect early decompensation given COPD. Continued skilled monitoring indicated.”
“O2 on.”
No flow, device, saturation, or rationale.
“SpO2 94% on 2 L per nasal cannula at the ordered target; cannula placement and oxygen safety verified; titration parameters reviewed.”
“Patient taught inhaler.”
No technique steps, method, or measured mastery.
“Reviewed metered-dose inhaler with spacer using return demonstration; corrected actuation timing; return-demo 9/9 steps; inhaled-corticosteroid mouth-rinse reinforced.”
“Encouraged to cough and deep breathe.”
Describes an activity, not a skilled action, and no response.
“Coached huff cough and pursed-lip breathing with the patient; correct technique demonstrated; sputum cleared and SpO2 improved 91 → 95%.”
“Resp WNL.”
A bare finding with no skilled rationale.
Use the Mode A short form, adding oxygenation and the RN-level reason tied to the diagnosis and regimen.
“SOB improved.”
Improvement not quantified.
“Dyspnea reduced after nebulizer; respiratory rate 24 → 18, SpO2 90 → 95%, accessory-muscle use resolved.”
