Documenting a Respiratory Exam - Just the Basics
A physical exam of the chest includes both the heart and lungs, which can each be quite complex in themselves. So, for our purposes, we'll break the exam and documentation of the chest down into its components. Continuing our MidlevelU series on documentation basics, today we'll look at how to document an exam of the respiratory system.
What You're Looking For
Examining the respiratory system consists of a number of components, namely inspection, auscultation, percussion, and palpation. Given the importance of the respiratory system, at least a basic exam should be conducted and documented on nearly all patients. Here's a quick review of what you're looking for:
- Inspection - Inspect the external chest noting the chest shape (ex. barrel chest as seen in COPD), respiratory rate, signs of respiratory distress, nature of breathing, and external appearance of the skin.
- Auscultation - Listen to lung sounds noting any abnormalities.
- Percussion - Percuss all lobes of the lung, front and back, listening for sounds that suggest complications like hyperinflation, consolidation, or effusion.
- Palpation - Check the position of the trachea, feel for symmetrical chest expansion, and test for tactile vocal fremitus.
Buzzwords to Know
As with most systems of the body, there are a few physical exam tricks you can do to help you reach your diagnosis. Here are the basic exam techniques you may reference in documenting your respiratory exam.
- Tactile Fremitus - A vibration of the chest wall when speaking that is palpable on exam. Respiratory abnormalities such as COPD, pleural effusion, and pneumothorax may impede or enhance these vibrations signaling a disease process to the examiner.
- Crepitus - A crackling or popping sensation felt under the skin as a result of subcutaneous emphysema. May be caused by trauma or rupture of the airway.
For patients presenting with respiratory complaints, or known respiratory system abnormalities, you will want to document a complete respiratory exam. For patients presenting with non-related problems, you can keep your respiratory system documentation to a minimum. The example provided here falls somewhere in the middle of this spectrum.
Documentation of a basic, normal respiratory exam should look something along the lines of the following:
The chest wall is symmetric, without deformity, and is atraumatic in appearance. No tenderness is appreciated upon palpation of the chest wall. The patient does not exhibit signs of respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes. Resonance is normal upon percussion of all lung fields.
Sample Abnormal Exam Documentation
Similar to documentation for other body systems, the more specific you can be about where a respiratory abnormality lies, and the quality of the abnormality itself, the better. You may note, for example, abnormal lung sounds at the lung bases vs. the apex, or on the right vs. the left side of the chest.
While you won't use all of these elements in documenting an abnormal respiratory exam, these are some of the abnormal physical findings you may need to note.
Abnormals on a respiratory exam may include:
- Respiratory distress (mild, moderate, severe)
- Decreased or absent breath sounds
- Increased or decreased respiratory rate
- Wheezing, rales, crackles, ronchi, or stridor
- Retractions, accessory muscle use, or nasal flaring
- Chest wall tenderness, chest wall bruising, rib tenderness, sternal tenderness
- Areas of increased or decreased tactile fremitus
- Depression or protrusion of the sternum (pectus excavatum or pectus carinatum)
**Note: This is not meant to be an exhaustive guide to examination and documentation. You are responsible for performing an appropriate physical exam and documenting your findings accordingly on each patient you interact with.
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These documentation updates have been terrific! Thanks Erin!