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RT Consult form side #1

RT Consult form side #1

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Published by Rick Frea
RT consult form/ page 1 (see RT consult form #2)

I had to make some adjustments to make this form fit scribt, but you get the general idea.

RT consult form/ page 1 (see RT consult form #2)

I had to make some adjustments to make this form fit scribt, but you get the general idea.

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Published by: Rick Frea on Dec 04, 2009
Copyright:Attribution Non-commercial

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05/26/2014

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( ) Initial Assessment/ Evaluation( ) Re-Assessment/ Evaluation
RECOMMENDED CARE PLAN:( ) Albuterol 0.5cc( ) Duoneb( ) Xoponex 1.25mg( ) Xoponex 0.63mg( ) Q2& prn( ) Q4 & prn( ) QID & prn ( ) Q6prn( ) Ventolin MDI Q6prn( ) 2.5mg Atrovent( ) Q4( ) Q8( ) QID( ) Atrovent MDI 2 puffsQID( ) IS instruct Q1 W/A( ) CPT QID & prn to tolerance ( ) Combivent MDI 2 puffsQIDOTHER RECOMMENDATIONS/ NOTES: ______________________________________________________________________________________  ______________________________________________________________________________________  ______________________________________________________________________________________  ______________________________________________________________________________________  ______________________________________________________________________________________ 
RRT signature/ Date/ Time__________________________________________________ Physician signature/Date/Time_______________________________________________ 
Respiratorytherapycave.blogspot.com
RESPIRATORY THERAPY CONSULT FORM
Patient LabelPATIENT INFORMATION:A Respiratory Therapist has evaluated this patient. Based on the patient’s clinical indications, the RespiratoryCare Plan designated below will be implemented.Date/Time of Assessment__________________ Ordering Physician _________________________________ Diagnosis_______________________________ Allergies: _________________________________________ Pre-existing pulmonary disease: ______________________________________________________________ Home Respiratory Orders: __________________________________________________________________ BASIC ASSESSMENT AND LABS: HR_____ RR_____ Temp_____ BP_______I&Os_________________ SpO2_____ FiO2/LPM_____ PEFR: pre _____post _____ Pred. PEFR______ PEFR effort_____ Hgb______ Lung sounds_______________________________WOB___________________________________________ ABG: Date/Time_________________ FiO2_____ SaO2_____ Ph_____ PO2_____ PCO2_____ HCO3_____ Smoking history: ( ) Yes ( ) No Cough_____________________ Secretions_________________________ INDICATORS FOR AEROSOL THERAPY: (check all that apply)( ) Bronchospasm/ wheezing( ) Asthma/ reactive airwaydisease( ) Diminished lung sounds ( ) COPD( ) Prolonged expiratory phase ( ) Obstructive defects of PFT( ) Impaired mucous clearance ( ) History of Pulmonary diseaseINDICATORS FOR HYPERINFLATION THERAPY:( ) Prolonged bed rest( ) Diminished Lung Sounds( ) Atelectasis( ) Abdominal/Thoracic surgery( ) Prevent Atelectasis ( ) Restrictive lung defectINDICATORS FOR BRONCHOPULMONARY HYGENE THERAPY:( ) Productive Cough( ) History of mucous producing disease( ) Rhonchi( ) Pneumonia MDI CRITERIA:1. Can physically performthe maneuver.2. Can follow directions.3. Is cooperative and alert.4. Can take a slow deepinspiration.5. Can hold breath for atleast five seconds.6. Is able to perform areturn demonstration.7. Respiratory rate <= 25

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