Assess respiratory status against the ordered parameters and document the skilled judgment:
Respiratory rate, effort (accessory-muscle use, retractions), and pattern; SpO₂ with the oxygen setting and delivery device; and lung sounds by field.
Cough and sputum (color, amount, consistency, change); for a tracheostomy, secretion characteristics, suction frequency, stoma/site condition, and tube security.
Response to respiratory treatments and oxygen within the ordered parameters; activity tolerance and dyspnea (a scale where used).
MDS-supportive data
Oxygen therapy, suctioning, tracheostomy care, ventilator/respirator, and isolation for an active infection are coded in MDS Section O0110; the respiratory diagnosis in Section I. The record must document the oxygen setting/days, the procedure, and the assessment so Section O is supported.
