Respiratory Therapy Competency and Documentation Guide

Author: Daniel Pino, RRT | Last Updated: 12/1/2024

What is Respiratory Therapy?

Respiratory therapy focuses on assessing, treating, and managing conditions affecting the respiratory system, which includes the lungs, airways, breathing muscles, and supporting structures. Due to the complexity of this system, a wide range of diseases and conditions can arise, including COPD, pneumonia, asthma, tuberculosis, pulmonary embolism, and post-surgical complications.

However, indications for respiratory therapy are not limited to respiratory diagnoses. Many conditions can indirectly affect breathing or increase the risk of complications such as pneumonia, atelectasis, shortness of breath (SOB), or increased work of breathing. Examples include neuromuscular disorders, post-surgical recovery, prolonged immobility, obesity hypoventilation syndrome, and cardiac conditions.

Interdisciplinary Roles in Respiratory Therapy

While nurses, physical therapists (PT), and occupational therapists (OT) can perform certain respiratory therapy tasks within their scope of practice, only time documented by respiratory therapists (RTs) or trained respiratory nurses can be captured on the MDS for reimbursement purposes.

• Each discipline must demonstrate competency in the specific modality they deliver
• Modalities performed by PTs or OTs cannot be included in MDS respiratory therapy minutes

Capturing and Coding Respiratory Therapy on the MDS

To ensure proper classification under the Special Care High RUG category, respiratory therapy must meet the following requirements:

1. Qualified Providers: Services must be provided by a respiratory therapist (RT) or a trained respiratory nurse with documented proficiency
2. Service Frequency: Delivered for at least 15 minutes per day for 7 consecutive days during the look-back period
3. Evaluation and Care Plan: An initial evaluation must identify deficiencies or abnormalities in pulmonary function and outline the patient's respiratory therapy needs. An individualized care plan must detail treatment goals and expected outcomes
4. Time Captured: Includes evaluation, treatment administration, monitoring, setup/removal of equipment, and patient education
5. Documentation: Time spent must be accurately recorded on the Medication Administration Record (MAR) or Treatment Administration Record (TAR)

Respiratory Therapy Assessment

Focused Interview: The focused interview is a vital diagnostic and therapeutic tool. During the interview, the clinician should address key topics such as smoking history, environmental exposures, medications, and recent hospitalizations related to respiratory health. The interview must identify the underlying condition or diagnosis linked to pulmonary function deficiencies, explain how the chosen respiratory modality will address the identified issue, and define clear therapy goals.

Inspect and Observe: Observation and inspection are core components of a respiratory assessment. Key observations include use of accessory muscles during breathing, symmetry of chest movements, and skin, lips, face, hands, and feet coloring for signs of cyanosis or poor perfusion.

Pre- and Post-Treatment Documentation: Every respiratory assessment must include pre- and post-treatment documentation, focusing on three primary areas: respirations, pulse oximetry, and auscultation findings.

• Respirations: Counted over 60 seconds by observing the chest rise and fall. Each rise and fall counts as one breath
• Pulse Oximetry: Measures oxygen saturation levels (SpO2) non-invasively, with normal levels typically at 89% or higher. A clip-like device is placed on the finger, earlobe, or toe
• Auscultation: Assesses airflow through the tracheobronchial tree. The clinician should listen symmetrically from the apices downward on both the front and back of the chest

Common Lung Sounds

• Vesicular (Normal): Soft, low-pitched sounds with longer inhalation than exhalation
• Crackles (Rales): Indicate fluid in the small airways, more common during inspiration
• Wheezes: High-pitched, whistle-like sounds caused by airway narrowing, often during expiration
• Rhonchi: Low-pitched, rattling sounds caused by upper airway secretions
• Stridor: High-pitched noise from airway obstruction, audible without a stethoscope
• Pleural Friction Rubs: Grating or crackling sounds caused by inflamed pleural surfaces

Medication Delivery Methods

Nebulizer Treatment: A nebulizer converts liquid medication into a fine mist or aerosol, allowing the patient to inhale the medication directly into their airways. This method is effective in treating conditions like bronchoconstriction and improving air exchange in the lungs. Time spent administering nebulizer treatments CAN be captured on the MDS.

MDI & DPI: Metered Dose Inhalers (MDIs) use a pressurized canister, while Dry Powder Inhalers (DPIs) rely on the patient's inhalation to deliver powdered medication. Although MDIs and DPIs are effective delivery methods, time spent administering these treatments CANNOT be captured on the MDS.

Deep Breathing Exercises

Deep breathing exercises are an essential component of respiratory therapy. They help alleviate symptoms of COPD, prevent pneumonia, aid in post-surgical recovery, and reduce breathlessness during physical activities. The five types of breathing exercises are:

• Pursed-Lip Breathing: Helps slow breathing, reduce shortness of breath, and promote better airflow
• Coordinated Breathing: Reduces breathlessness during physical exertion and helps regulate breathing during activity
• Deep Breathing: Helps expand lung capacity, improve oxygen intake, and reduce anxiety
• Huff Cough: Used to clear mucus from the airways effectively without causing excessive fatigue
• Diaphragmatic Breathing (Belly Breathing): Promotes efficient use of the diaphragm, reducing the effort required for breathing

Incentive Spirometry

An incentive spirometer is a medical device used to help patients improve lung function, prevent lung complications, and encourage slow, deep breathing after surgery or illness. Goals include preventing or treating atelectasis, improving oxygenation and lung expansion, reducing the risk of pneumonia, enhancing airway clearance, and decreasing shortness of breath.

Cough Therapy Modalities

Cough therapy modalities are essential tools for airway clearance, secretion mobilization, and preventing respiratory complications such as pneumonia or atelectasis. These include:

• Acapella/Flutter Valve Therapy: A handheld device designed to help mobilize mucus from the airways by combining positive expiratory pressure (PEP) with vibrations
• Chest Physical Therapy (CPT): Uses physical techniques including postural drainage, percussion, vibration, deep breathing, and directed coughing to mobilize and remove mucus
• High-Frequency Chest Wall Oscillation (Chest Vest): An inflatable vest attached to a machine that delivers rapid vibrations across the chest to loosen and thin mucus
• Cough Assist Device: A mechanical tool designed for patients who cannot generate a strong enough cough, mimicking a natural cough by delivering positive and negative pressure

Note: All assessments, findings, and therapy goals must be documented in detail in the patient's record. Documentation must meet state-specific regulations and should be accurate, complete, and timely to ensure compliance and support optimal patient outcomes.