Listening to the sounds of air moving through the lungs (auscultation) is a fundamental part of any comprehensive health assessment. The sounds heard through a stethoscope offer direct insights into the condition of the airways and surrounding lung tissue. Accurate documentation, or charting, is necessary for consistent communication among healthcare professionals. Standardized charting ensures that any change in a patient’s respiratory status is clearly logged, allowing for prompt medical intervention. This structured approach moves the assessment from a subjective listening event to objective, actionable medical data.
The Foundation: Normal vs. Adventitious Sounds
The first step in precise charting is distinguishing between expected and unexpected respiratory noises. Normal breath sounds are categorized into three main types based on where they are heard: vesicular, bronchovesicular, and bronchial. Vesicular sounds are soft and low-pitched, created by air moving through the smaller airways, and are heard most widely over the chest wall. Bronchial sounds are loud, high-pitched, and hollow, typically heard only over the trachea, reflecting air movement through the large, main airways. Bronchovesicular sounds represent an intermediate pitch and intensity, usually found over the sternum and between the shoulder blades.
Adventitious sounds, also known as abnormal sounds, are those heard in addition to or instead of the expected breath noises. These findings suggest an underlying issue, such as fluid, mucus, or airway obstruction. Turbulent airflow due to narrowing or secretions creates adventitious sounds that disrupt the smooth quality of normal air movement. Charting requires a clear differentiation because the presence of adventitious sounds immediately signals a potential pathology requiring further investigation.
Anatomical Mapping for Precise Charting
The location where a sound is heard is equally important to the sound’s quality, making a standardized anatomical map essential for charting. The lungs are divided into lobes, and charting utilizes precise abbreviations to pinpoint the area of the finding. The right lung has the Right Upper Lobe (RUL), Right Middle Lobe (RML), and Right Lower Lobe (RLL). The left lung consists only of the Left Upper Lobe (LUL) and Left Lower Lobe (LLL).
Healthcare providers also specify the field of the chest—anterior (front), posterior (back), or lateral (side)—in conjunction with the lobe abbreviation. This locational specificity is important because certain lobes are more accessible from the front or back; for example, the RML is best assessed anteriorly. Assessment requires a bilateral comparison to detect subtle differences in airflow. Identical findings on both sides can be charted efficiently using the term “bilaterally,” while asymmetrical findings must be documented by specifying the lobe and side (e.g., “RLL” or “LUL”).
Standard Note Format and Descriptive Terminology
A standardized note format ensures that all relevant details about the auscultation are captured clearly. The charting entry typically begins with the time of the assessment and the patient’s position, as posture can affect sound transmission. The note must then describe the general character and intensity of the sounds. Terms like “Clear,” “Diminished,” “Absent,” or “Equal” are used to describe the overall quality of air entry across the lung fields.
When charting a normal finding, the phrase “Lungs Clear to Auscultation bilaterally” (CTA bilaterally) is used, meaning expected vesicular sounds were heard without adventitious noises. For a more detailed normal report, the note might specify “Vesicular sounds present and equal bilaterally, unlabored effort noted.” The timing of the sound within the respiratory cycle is also necessary, specifying if the air movement is heard during inspiration or expiration. “Diminished” breath sounds indicate that the volume of air movement is reduced over a specific lobe or field (e.g., “Breath sounds diminished LLL posterior”).
Documenting Specific Adventitious Findings
When pathological sounds are present, charting must transition from general descriptors to specific, standardized terminology to convey the nature of the abnormality. The three most common specific adventitious findings are crackles, wheezes, and rhonchi, each requiring detailed documentation. Crackles, formerly known as rales, are discontinuous, brief, non-musical sounds. They can be qualified as fine (high-pitched, heard mainly on inspiration) or coarse (low-pitched, wet-sounding). A precise chart note might read: “Fine inspiratory crackles noted at bilateral bases, posterior field.”
Wheezes are continuous, musical sounds generated by narrowed airways, and are typically heard loudest during expiration. These are described by their pitch, such as “high-pitched expiratory wheezes” or “low-pitched monophonic wheezes.” Rhonchi are also continuous but are lower-pitched, snoring-like sounds that often indicate secretions or fluid in the larger airways. Whether the sound changes or “clears” after the patient coughs is an important detail, suggesting the sound is due to movable secretions. All adventitious findings should be accompanied by notes regarding associated symptoms, such as the presence of a cough or sputum production, to provide a complete clinical picture.