What to include in a pulmonary referral
Two patients with identical ventilator settings can need different care. For a pulmonary review, describe the patient’s usual breathing support, what has changed and what still limits activity.
Trace the change from baseline
Give the patient’s usual support before illness, the reason for the current airway and the direction of change. Include recent oxygen and secretion needs.
Describe activity at the bedside
Describe what happened during the most recent attempt to sit up, speak or participate in therapy. Record the assistance required and the patient’s response.
Connect related treatments
Identify treatments that must be coordinated with respiratory care. Give the next scheduled time for dialysis, IV therapy or wound treatment when relevant.