Respiratory Care Protocols and Soap Notes

RT Consult Service

• MD writes order for protocol/consult, and RN/unit secretary notifies RT evaluator
• RT assesses patient according to guidelines and writes care plan using indications and algorithms
• Care plan is documented in chart for MD review
• RT covering unit delivers care and assesses patient for changes in status and modifications

Quality Assurance Plan

• JCAHO requires a quality assurance plan
• Quality assurance plan provides a system for quality control and continuous quality improvement (CQI)
• CQI is an ongoing process designed to detect and correct factors hindering provision of quality and cost-effective healthcare

9 Steps for a Quality Assurance Plan

• Identify problems
• Determine causes
• Rank problems
• Develop strategies to resolve problems
• Develop measurement techniques
• Implement problem-resolution strategies
• Analyze and compile results
• Report results
• Evaluate outcome of intervention

Goals of a RT CQI Plan (AARC)

• Provide a method for ongoing monitoring of quality and appropriateness of care
• Ensure cost-effective methods and procedures
• Ensure effective methods and procedures
• Identify, rank, and resolve patient-care-related issues

Methods of Monitoring

• Audit system
• Feedback must be given
• Case studies
• S.O.A.P Notes (Subjective, Objective, Assessment, and Plan)

S.O.A.P Notes

• Subjective data: information obtained from patient, relatives, or similar sources
• Objective data: information based on caregivers' observations, physical exam, or diagnostic/lab tests
• Assessment: analysis of patient's problem
• Plan: course of action to resolve the problem

RT Protocols

• Developed to enhance allocation of respiratory care services
• Can show a decrease in misallocated care
• Guidelines for delivering appropriate treatments and services
• Written in outline form or as an algorithm

Key Elements of a Respiratory Care Protocol Program

• Strong and committed medical direction
• Engaged therapists
• Active quality monitoring
• Collaborative environment (RTs, MDs, RNs)
• Responsiveness of all elements to address and correct problems

Elements of Acceptable RT Protocol (ACCP)

• Clearly stated objectives
• Outline includes algorithm
• Description of alternatives found at action points
• Description of possible complications and how to correct them
• Description of end points and decision points where MD contact is needed

Protocol Program Advantages

• Better allocation of services
• Cost-savings
• More dynamic respiratory care
• Adjustment of services to keep pace with patient needs
• More versatile use of services