Standard Lung Examination Documentation Format
Document lung examination findings systematically using the four-step sequence: inspection, palpation, percussion, and auscultation, with specific attention to abnormal findings that guide clinical decision-making. 1
Inspection
Document the following visual findings:
- Respiratory rate (breaths per minute) 1
- Work of breathing: presence or absence of accessory muscle use, chest retractions 2
- Chest wall symmetry and movement
- Patient position (sitting, standing, supine) 3
- Signs of respiratory distress 2
Palpation
Record tactile findings including:
- Chest wall tenderness or pain location 4
- Tactile fremitus (increased or decreased)
- Chest expansion symmetry 5, 6
Percussion
Document percussion notes as:
- Normal/resonant
- Dull (suggests consolidation, pleural effusion, or mass)
- Hyperresonant (suggests pneumothorax or emphysema)
- Note specific locations of abnormal findings 4, 6
Auscultation
The lung examination by auscultation should document: 1
- Clear or normal breath sounds
- Rales/crackles - specify height when patient is sitting upright (e.g., "rales to mid-lung fields")
- Decreased breath sounds or dullness - specify location
- Rhonchi - coarse, low-pitched sounds
- Wheezing - high-pitched whistling sounds on expiration or inspiration 7, 2
- Other findings such as pleural rub, stridor 1, 7
Critical Documentation Points
Always specify:
- Whether findings are unilateral or bilateral
- Specific lung zones affected (upper, middle, lower fields)
- Changes with position or deep breathing
- Oxygen saturation at time of examination 2, 8
Common Pitfalls to Avoid
The most frequent documentation errors include:
- Failing to specify the height of rales in the lung fields - this is essential for assessing heart failure severity 1
- Recording only "decreased breath sounds" without specifying location
- Omitting respiratory rate, which is a vital sign 1
- Not documenting patient position, which affects findings particularly in obese patients 3
Document abnormal findings with anatomic precision (e.g., "rales extending to scapular level bilaterally" rather than just "rales present") to enable meaningful comparison on subsequent examinations and guide treatment decisions 1, 5.