Accurate charting of lung sounds serves as the official, standardized record for a patient’s respiratory status. This documentation acts as the formal communication tool for the entire healthcare team. Precise terminology ensures every clinician understands the exact findings, which is crucial for tracking the progression or improvement of a patient’s condition over time. The medical chart provides a legal record and allows for immediate comparison of current observations against previous baselines, supporting timely clinical decisions.
Documenting Normal Lung Sounds and Basic Structure
Every charting entry begins with foundational information that sets the context for the observation. This includes the date, the exact time of the assessment, and the patient’s position during auscultation. While the patient is ideally sitting upright for a thorough assessment, the documentation must reflect if they were supine or turned to a side. When lung sounds are within the expected range, the common charting abbreviation is “Clear to Auscultation Bilaterally,” or CTAB.
A more detailed entry specifies the expected normal breath sounds, which are classified based on location. Vesicular sounds are soft, low-pitched, and heard over most lung fields, with the inspiratory phase being significantly longer than the expiratory phase.
Bronchovesicular sounds are intermediate in pitch and intensity, with inspiration and expiration being roughly equal in duration. They are typically heard over the major airways between the scapulae and near the sternum. Bronchial sounds are loud and high-pitched, with a longer expiratory phase, and are expected only over the trachea. Charting these specific sound types is relevant if a sound is heard outside its normal location, which can signal consolidation or underlying pathology.
Standardized Terminology for Adventitious Sounds
When abnormal sounds are detected, standardized terminology is necessary to convey the precise nature of the finding. These extra sounds, known as adventitious sounds, are categorized by their pitch, duration, and whether they are continuous or discontinuous. The term wheeze describes a continuous, high-pitched, musical sound, most often heard during expiration as air is forced through narrowed airways, such as in asthma. Wheezes are sometimes distinguished as sibilant (high-pitched) or sonorous (lower-pitched and snoring-like, sometimes called rhonchi).
Crackles, previously known as rales, are discontinuous sounds described as popping or bubbling noises. They are divided into two types based on characteristics. Fine crackles are high-pitched, short, and sound similar to hair being rolled between the fingers, often indicating fluid in the small airways or alveoli.
Coarse crackles are lower-pitched, longer, and louder, suggesting the presence of secretions in the larger airways. The term rhonchi describes a low-pitched, continuous, rattling sound that may clear or change after the patient coughs, differentiating it from crackles.
Two other distinct adventitious sounds require specific charting: stridor and pleural friction rub. Stridor is a harsh, high-pitched, crowing sound heard primarily on inspiration, indicating an obstruction in the upper airway. A pleural friction rub is a low-pitched, grating, or creaking sound, comparable to walking on fresh snow, caused by inflamed pleural surfaces rubbing together during both inspiration and expiration.
Specifying Location, Timing, and Qualitative Descriptors
A complete charting entry for an adventitious sound must specify its location, timing within the respiratory cycle, and intensity or extent. Anatomical location is charted using standardized abbreviations for the lung lobes: RUL, RML, RLL, LUL, and LLL. Precision is added by noting the area as anterior, posterior, or lateral (e.g., “RLL posteriorly”). The timing is designated as inspiration (insp), expiration (exp), or both, which helps determine the underlying cause.
Qualitative descriptors convey the sound’s severity and distribution. “Diminished” breath sounds indicate poor air movement. Descriptors include “localized” (confined to a small area), “scattered” (multiple non-contiguous areas), or “diffuse” (heard widely across all lung fields). Combining these elements creates a precise clinical statement. Examples include: “Fine crackles noted LLL posteriorly on insp, moderate in intensity,” or “Diminished breath sounds with scattered exp wheezes bilaterally, diffuse across all lobes.”