The accurate and consistent documentation of mechanical ventilation is a fundamental requirement for patient safety and effective care coordination. This record-keeping ensures that all members of the healthcare team, including respiratory therapists, nurses, and physicians, have a clear, shared understanding of the patient’s respiratory support. Precise documentation acts as a legal record and is the foundation for making informed adjustments to therapy, which ultimately impacts the patient’s outcome and the trajectory toward weaning from the ventilator.
Core Ventilator Input Settings
The initial documentation focuses on the parameters the clinician physically programs into the device. The record must clearly identify the specific mode of ventilation being used, such as Volume Control Ventilation (VCV), Pressure Control Ventilation (PCV), or Pressure Support Ventilation (PSV). This distinction is necessary because each mode delivers breaths differently, either by fixing the volume or the pressure.
For Volume Control modes, the set respiratory rate (f) and the set tidal volume (Vt) are required, with the tidal volume often recorded in milliliters per kilogram of predicted body weight to align with lung-protective strategies. In contrast, for Pressure Control modes, the inspiratory pressure (Pinsp) and inspiratory time (Ti) are the documented settings that determine the breath size. Regardless of the mode, the Fraction of Inspired Oxygen (FiO2) and the Positive End-Expiratory Pressure (PEEP) are always documented, as these two parameters directly influence the patient’s oxygenation.
Documentation also involves recording the high and low alarm limits for parameters like pressure, minute ventilation, and tidal volume. These limits must be individualized for the patient and serve as an early warning system for potential complications or disconnects.
Measured Patient Mechanics and Physiological Data
Documentation must strictly separate the clinician’s input settings from the patient’s measured response. A primary measurement is the Peak Inspiratory Pressure (PIP), which is the maximum pressure reached during the inspiration phase of a breath. Clinicians must also perform and record the Plateau Pressure (Pplat), obtained by an end-inspiratory breath hold maneuver, which represents the pressure in the small airways and alveoli when airflow is zero.
The difference between Pplat and PEEP calculates the driving pressure, a measure considered predictive of potential ventilator-induced lung injury. These pressure measurements allow for the calculation of lung compliance, distinguishing between static compliance (elastic recoil) and dynamic compliance (including airway resistance), which indicates the stiffness of the lungs. The documentation of patient effort is also necessary, including the patient’s spontaneous respiratory rate, which is the number of breaths initiated by the patient above the set machine rate.
Beyond the mechanical outputs, physiological data directly reflecting gas exchange must be recorded to assess the therapy’s efficacy. This includes continuous monitoring like pulse oximetry (SpO2) and end-tidal CO2 (EtCO2). Furthermore, the results and time of the most recent Arterial Blood Gas (ABG) analysis must be noted, as this provides the definitive measure of oxygenation (PaO2) and ventilation (PaCO2) that guides subsequent ventilator adjustments.
Standardized Documentation Frequency and Format
Documentation of all settings and patient measurements is typically mandated at a minimum frequency, often hourly, and immediately upon a change in the patient’s status or at the beginning of a shift change. This consistent timing ensures that a current baseline is always established for the incoming care provider.
To minimize errors, standardized templates, whether electronic health record flowsheets or paper charts, must be utilized for every documentation instance. These formats help ensure that no necessary data point is missed during the check. Accuracy requires that every entry includes an unambiguous time stamp, clearly indicating when the reading was taken or the setting was changed.
All entries must be legible and use only approved, standardized clinical abbreviations to avoid misinterpretation. Accountability is enforced by requiring the clinician who performs the check and enters the data to sign or verify the entry, linking the action to a responsible party. This procedural rigor is what transforms a collection of data points into a reliable, actionable, and legally sound clinical record.
Documenting Changes Interventions and Special Circumstances
When a change is made to any ventilator setting, the documentation must capture the rationale for the change, the new setting, and the patient’s immediate response to that adjustment. This provides a clear, chronological narrative of the therapeutic decision-making process, ensuring the next clinician understands the intent and effect of the modification.
Documentation must also encompass related procedural interventions that may temporarily affect the patient-ventilator system. This includes noting the time and result of procedures such as endotracheal suctioning, which can acutely alter airway pressures, or the replacement of the ventilator circuit. The periodic monitoring and recording of endotracheal tube cuff pressure, which helps prevent tracheal injury or air leaks, is also a required intervention.
Special clinical circumstances necessitate specific documentation to ensure patient safety across transitions of care. During intra-hospital transport, all ventilator settings must be documented immediately before and after the transfer, as temporary ventilation devices may be used, and setting discrepancies pose a risk. Similarly, the initiation or cessation of a weaning trial, such as a Spontaneous Breathing Trial (SBT), requires detailed charting of the weaning parameters and the patient’s tolerance or failure of the trial.