Lorma Colleges

College of Physical and Respiratory Therapy

S.Y. 2015-2016

RESPIRATORY THERAPY
MONTHLY TREATMENT RECORD

Affiliation Center: ________________________________ Month:

______________________

NEBULIZATION
DATE PATIENT’S NAME AGE FREQUEN MEDICATION MODE OF
(INITIALS) CY DELIVERY

MECHANICAL VENTILATION
DATE PATIENT’S NAME AG CONTROL PARAMETERS REMARKS
(INITIALS) E

ARTERIAL BLOOD GAS

DATE PATIENT’S NAME AGE pH PaCO HCO3 PaO2 INTERPRETATI
(INITIALS) 2 ON

OTHERS (Tracheal Care / Suctioning / Sterilization Technique / PFT etc.)

DATE PATIENT’S NAME (INITIALS) RT PROCEDURE

INTERN’S NAME: _____________________________ RT STAFF:

_________________________________