Pulmonary Embolism

Minimum Data for completing RT220
Case Study
1. Patient Data – Age, Gender, Race
2. Chief Complaint and History of present illness, include:
a. Smoking history (if applicable)
b. Work History
c. Social History
3. Date of admission, Diagnosis, Secondary Diagnosis (if applicable)
4. Current Medications taken (Include; Type, dosage, and why taking)
5. Admitting Assessment to confirm diagnosis including:
a. Patient interview
b. Vital signs (Heart rate, RR, BP, Temp., SpO2
c. Auscultation
d. Sputum (if applicable)
e. X-ray
f. Lab work including ABG (if applicable)
6. Initial Therapeutic interventions including any respiratory interventions and outcomes. (Based on assessment)
7. If intubated or trached include:
a. Size of tube
b. Orally or nasally intubated (if trach, size and type of trach)
c. Tube placement at the teeth or gum line
8. If on a vent include Patient and vent parameters including:
a. Mode
b. Vent rate/ Total rate
c. Tidal Volume
d. FIO2
e. Peep (if applicable)
9. After initial assessment and interventions, you must have the disposition (plan) for the patient.
10. Follow the patient daily, indicating what therapeutics are being done, what meds are given and why, changes in patients condition, any follow-up testing, changes in test results, and any changes in therapeutics.
a. If patient is on a vent, show ABG’s for each day and indicate any vent adjustments that were made
11. Final disposition (Discharged, Transferred, Deceased etc.)
It is important to keep things in chronological order that is easy to follow. Remember you are giving use a picture of what occurred with your patient from time of admission to final disposition.

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