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Respiratory Therapy Evaluation and Flow Record Assessment Reference Date ARD

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					                                                 Respiratory Therapy Evaluation and Flow Record

Assessment Reference Date (ARD): _______________                                                                          Month: ___________     Year:_____________

Directions: For the North Carolina MDS Validation Review, a trained, licensed nurse (or Respiratory Therapist) must complete an initial
assessment, document the plan of treatment and must evaluate the resident’s response to the treatment at least once within the observation
period. (The evaluation might include such items as lung sounds, congestion, cough, sputum, dyspnea, oxygen, call to physician, new orders,
etc.) Each nurse completing respiratory treatments must be trained in the treatment(s) being provided. Treatment must be ordered by a
physician, be medically necessary and be documented in the clinical record. Count only the time the qualified professional spends with the
resident. Direct respiratory therapy days and minutes with associated initials/signature(s) must be provided.

NOTE: A trained, licensed nurse may perform the assessment and treatments when permitted by the state nurse practice act.

Treatment Order: __________________________________________________________________________________________________


               1     2    3     4    5   6   7   8   9   10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time/min
  Initials
Time/min
  Initials
Time/min
  Initials
Time/min
  Initials

 Initials                           Full Signature and Title                           Initials                            Full Signature and Title




                                                               Full signatures required to authenticate initials.


                                    Resident Name                                                Medical Record Number                         Room Number


Prepared by Myers and Stauffer LC                                                         1                                                             Version 1 2007
                                                           This form is not endorsed by any state or government agency.
                                               Respiratory Therapy Evaluation and Flow Record

Assessment Reference Date (ARD): _______________                                                                     Month: ___________    Year:_____________

Trained, licensed nurse or Respiratory Therapist evaluation of resident’s response to treatment (Must be within the observation period):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

Additional notes:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________


                                    Resident Name                                            Medical Record Number                        Room Number




Prepared by Myers and Stauffer LC                                                    2                                                            Version 1 2007
                                                      This form is not endorsed by any state or government agency.
                                                  Respiratory Therapy Evaluation and Flow Record
                                                                                                                                                    Month: ____________
                                                                                                                                                    Year: ____________
Directions: For the North Carolina MDS Validation Review, a trained, licensed nurse (or Respiratory Therapist) must complete an initial
assessment, document the plan of treatment and must evaluate the resident’s response to the treatment at least once within the observation
period. (The evaluation might include such items as lung sounds, congestion, cough, sputum, dyspnea, oxygen, call to physician, new orders,
etc.) Each nurse completing respiratory treatments must be trained in the treatment(s) being provided. Treatment must be ordered by a
physician, be medically necessary and be documented in the clinical record. Count only the time the qualified professional spends with the
resident. Direct respiratory therapy days and minutes with associated initials/signature(s) must be provided.
NOTE: A trained, licensed nurse may perform the assessment and treatments when permitted by the state nurse practice act.

Trained, licensed nurse or Respiratory Therapist Initial Evaluation/Assessment (Must be within the observation period):
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

Treatment Order: __________________________________________________________________________________________________

               1     2      3    4   5   6    7    8    9   10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time/min
  Initials
Time/min
  Initials
Time/min
  Initials
Time/min
  Initials

  Initials                            Full Signature and Title                                 Initials                         Full Signature and Title



                                                                     Full signatures required to authenticate initials.
                                     Resident Name                                                         Medical Record Number                      Room Number



Prepared by Myers and Stauffer                                                                                                                             Version 2   2007
                                                                 This form is not endorsed by any state or government agency.

				
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