Respiratory

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Trace DC41-6

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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4. Normal findings

The reference range below is the yardstick for “normal/at-baseline.” Normal findings are documented in Mode A with the skilled rationale that follows in Section 6 — never as “WNL” alone.

  • Respiratory rate 12–20 and unlabored, with a regular pattern.
  • Lung fields clear to auscultation in all anterior, lateral, and posterior fields bilaterally.
  • SpO2 at or above 95% on room air, or at the patient's ordered oxygen target.
  • No accessory-muscle use, retractions, nasal flaring, or pursed-lip breathing.
  • Speaks in full sentences without dyspnea.
  • Denies cough, sputum production, hemoptysis, or pleuritic chest pain.
  • Chest expansion symmetric; no cyanosis or digital clubbing.
  • Respiratory status at the patient's baseline.
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