Guide — RT Career & Professional Practice
Medical Documentation & Charting
The chart is a clinical communication tool and a legal record at once. This guide covers what RTs must document, the standard note formats, how to correct errors safely, and the abbreviations the Joint Commission says never to use.
8 min read · RT Career & Professional Practice
Written by Apex Respiratory Editorial Team
Educational use only. This material supports respiratory therapy education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional protocols, or physician orders. Always follow facility policies and current provider orders, and verify calculations independently before clinical use.
Overview
Documentation records the care delivered and the patient's response. It serves clinical communication, continuity of care, reimbursement, quality improvement, and legal defense. The guiding legal principle is straightforward: if it was not documented, it is treated as not done.
Every RT entry in the medical record must be objective, accurate, complete, and contemporaneous — meaning recorded as close to the time of care as possible. A well-kept chart protects the patient, the clinician, and the institution.
Key Concepts
A complete respiratory therapy entry captures five categories of information:
- Therapy delivered. Device used, settings (FiO₂, flow, tidal volume, frequency, dose), duration, and technique.
- Pre- and post-assessment. Breath sounds, SpO₂, vital signs, work of breathing, and any relevant physical findings before and after treatment.
- Patient response and adverse events. Whether the patient tolerated the therapy, any change in condition, and any unplanned events or interventions.
- Education provided.What was taught, the patient's or caregiver's demonstrated understanding, and any barriers to learning.
- Team communication. Physician notifications, orders received or clarified, and significant handoff information.
Use objective language. Avoid judgmental or subjective terms. Chart what you observed and measured, not your interpretation of the patient's character or cooperation.
Note Formats
Several structured formats are used in respiratory and acute care documentation. Each organizes information differently for different purposes.
| Format | Stands For | Best Used For |
|---|---|---|
| SOAP | Subjective, Objective, Assessment, Plan | General progress notes; organizes the clinician's reasoning in a standard sequence. |
| SOAPIER | SOAP + Intervention, Evaluation, Revision | Extended SOAP that explicitly tracks what was done, how the patient responded, and any plan changes. |
| SBAR | Situation, Background, Assessment, Recommendation | Handoffs and rapid verbal or written communication; designed to convey critical information concisely. |
| Narrative | Free-text chronological account | Detailed event documentation; flexible but less structured — requires discipline to stay objective. |
| Charting by Exception | Only deviations from established norms are charted | Reduces repetitive normal-findings entries; assumes all unchecked standards were met. |
SBAR is particularly important for respiratory therapists because it structures urgent communication with physicians — for example, when calling to report a patient's deteriorating SpO₂ or a ventilator alarm. Leading with the Situation and ending with a clear Recommendation reduces ambiguity and response time.
Legal and Safety Principles
Medical records are legal documents. The way an RT documents — or fails to document — can have serious consequences in audits, regulatory reviews, and litigation.
- Chart contemporaneously. Record care as soon as possible after it is delivered. Delays invite questions about accuracy.
- Never alter or backdate a record. This is falsification — a serious legal and professional violation. To correct an error, draw a single line through it, initial and date the correction, and note the reason. To add information later, write a clearly labeled late entry with the current date and time.
- Avoid prohibited abbreviations. The Joint Commission maintains an Official Do Not Use List. Using these abbreviations has caused serious medication errors and is a patient safety risk.
- Write leading zeros; omit trailing zeros. Write 0.5 mg, not .5 mg. Write 1 mg, not 1.0 mg. Misread decimal points have caused tenfold dosing errors.
Do Not Use abbreviations — reference table. The following abbreviations are on the Joint Commission's official list and must never appear in a medication order or clinical entry.
| Do Not Use | Why It's Dangerous | Use Instead |
|---|---|---|
| U / u | Mistaken for 0, 4, or cc | Write "unit" |
| IU | Mistaken for IV (intravenous) or the number 10 | Write "international unit" |
| Q.D. / Q.O.D. | Period after Q mistaken for "I"; O mistaken for I | Write "daily" or "every other day" |
| 1.0 mg (trailing zero) | Decimal point missed — reads as 10 mg | Write 1 mg (no trailing zero) |
| .5 mg (missing leading zero) | Decimal point missed — reads as 5 mg | Write 0.5 mg |
| MS / MSO4 / MgSO4 | Confused between morphine sulfate and magnesium sulfate | Write "morphine sulfate" or "magnesium sulfate" in full |
Common Pitfalls
- Treating undocumented care as having happened. If care is not in the record, it legally and clinically did not occur — regardless of what was actually done.
- Altering or backdating a record. Even well-intentioned edits made after the fact can constitute falsification. Use late entries and single-line corrections with initials and dates.
- Using prohibited or ambiguous abbreviations. Abbreviations on the Do Not Use list remain common in practice despite known risks. Defaulting to written-out terms eliminates the hazard entirely.
- Trailing zeros and missing leading zeros. These decimal formatting errors have caused tenfold medication dose errors and are entirely preventable.
- Subjective or judgmental language.Words like “uncooperative” or “difficult” are opinion. Chart observed behavior instead: “patient declined therapy and stated reason.”
- Copy-forward errors in the EHR.Carrying yesterday's note forward without updating it introduces inaccurate information and undermines the record's reliability.
Key Takeaways
- Not documented means not done. The chart is the legal and clinical record of care — incomplete documentation has real consequences.
- Document objectively and contemporaneously. Record what you observed and measured, as soon as possible after delivering care.
- Never alter a record. Correct errors with a single line through them — initialed and dated. Add missing information as a labeled late entry.
- Avoid Do Not Use abbreviations. Write out unit, international unit, daily, every other day, morphine sulfate, and magnesium sulfate in full.
- Always write a leading zero; never write a trailing zero. 0.5 mg, not .5 mg. 1 mg, not 1.0 mg.
FAQ
What must a respiratory therapist document?
RTs must document the therapy delivered (device, settings, dose), the assessment before and after (breath sounds, SpO₂, vital signs, work of breathing), the patient's response and any adverse events, education provided, and communication with the care team. Entries should be objective, accurate, complete, and made as close to the time of care as possible.
What do SOAP and SBAR mean?
SOAP stands for Subjective, Objective, Assessment, Plan — a structured format for progress notes that organizes clinical findings and the clinician's reasoning. SBAR stands for Situation, Background, Assessment, Recommendation and is used primarily for handoffs and verbal or written communication between providers to convey critical information quickly and clearly.
How do you correct a charting error?
Draw a single line through the error, initial and date the correction, and briefly note the reason (e.g., "error — wrong patient"). Never erase, white out, or obscure the original entry. If you need to add information after the fact, write a clearly labeled late entry with the current date and time and a note indicating when the care actually occurred.
What are the Joint Commission Do Not Use abbreviations?
The Joint Commission's Official Do Not Use List includes: U or u (for unit — can be mistaken for 0 or 4), IU (international unit — can be mistaken for IV or the number 10), Q.D. and Q.O.D. (daily and every other day — periods create confusion), a trailing zero after a decimal (e.g., 1.0 mg — the zero can be missed), a missing leading zero before a decimal (e.g., .5 mg instead of 0.5 mg), and MS, MSO4, and MgSO4 (ambiguous drug abbreviations). Write out the full term in every case.
Go deeper
SOAP, SBAR, SOAPIER, charting by exception — compare the documentation formats and when each fits.
Compare documentation formats →Related Resources
Sources
- Kacmarek RM, Stoller JK, Heuer AJ. Egan's Fundamentals of Respiratory Care. 12th ed. Elsevier; 2021. Recording and communicating clinical data.
- The Joint Commission. Official Do Not Use List of Abbreviations. The Joint Commission.