Emergency Department MDM Template for Shortness of Breath
Initial Assessment
Oxygen therapy should be administered immediately to achieve a target oxygen saturation of ≥90% in patients presenting with shortness of breath and hypoxemia. 1
Vital Signs
- Respiratory rate: _____
- Heart rate: _____
- Blood pressure: _____
- Temperature: _____
- SpO2: _____% on _____ L/min or _____ % FiO2
- Work of breathing: □ Mild □ Moderate □ Severe
Positioning
- Patient positioned: □ Semi-recumbent (30-45° head elevation) □ Lateral position (if unconscious)
Oxygen Therapy Management
Initial Oxygen Delivery Device Selected:
□ Nasal cannula (1-2 L/min) for mild hypoxemia, target SpO2 94-98% □ Simple face mask (5-6 L/min) for moderate hypoxemia, target SpO2 94-98% □ Venturi mask 24-28% (2-6 L/min) for COPD/hypercapnic risk, target SpO2 88-92% □ Reservoir mask (15 L/min) for severe hypoxemia, target SpO2 94-98% □ High-Flow Nasal Cannula (HFNC) for persistent hypoxemia despite conventional oxygen therapy 2
Special Considerations
□ COPD/risk of hypercapnia: Target SpO2 88-92% 3 □ Severe asthma: Target SpO2 94-98% □ Heart failure: Target SpO2 94-98% 3 □ Pregnant patient: Target SpO2 >94% □ Palliative care: Target symptom relief rather than specific SpO2 3
Diagnostic Studies
Immediate Studies Ordered:
□ Arterial Blood Gas (ABG) on _____ % FiO2
- pH: _____
- PaO2: _____ kPa/mmHg
- PaCO2: _____ kPa/mmHg
- HCO3: _____ mmol/L
- Base Excess: _____
□ Chest X-ray findings: _____ □ ECG findings: _____ □ Complete Blood Count: WBC _____ Hgb _____ Plt _____ □ Basic Metabolic Panel: Na _____ K _____ Cl _____ HCO3 _____ BUN _____ Cr _____ □ Troponin: _____ □ BNP: _____ □ D-dimer: _____ □ Sputum culture sent: □ Yes □ No □ Blood cultures sent: □ Yes □ No
Additional Studies (as indicated):
□ CT scan: _____ □ Pulmonary function tests: _____ □ Echocardiogram: _____ □ Other: _____
Differential Diagnosis
□ COPD exacerbation □ Asthma exacerbation □ Pneumonia □ Heart failure/pulmonary edema □ Pulmonary embolism □ Pneumothorax □ COVID-19 □ Other: _____
Treatment Plan
Respiratory Support:
□ Continue current oxygen therapy □ Escalate oxygen therapy to: _____ □ Consider Non-Invasive Ventilation (NIV) if pH <7.35 or PCO2 significantly elevated 1 □ Consider HFNC for persistent hypoxemia despite conventional oxygen 2 □ Intubation criteria met: □ Yes □ No
Medications:
□ Bronchodilators: □ Beta-agonist □ Anticholinergic □ Both 3
- Medication: _____ Dose: _____ Route: _____ Frequency: _____ □ Corticosteroids: Medication: _____ Dose: _____ Route: _____ Duration: _____ □ Antibiotics: Medication: _____ Dose: _____ Route: _____ Duration: _____ □ Diuretics: Medication: _____ Dose: _____ Route: _____ □ Anticoagulation: Medication: _____ Dose: _____ Route: _____ □ Opioids for palliative dyspnea management (if appropriate): _____ 3 □ Other: _____
Monitoring Plan:
□ Continuous pulse oximetry □ Repeat ABG in _____ hours □ Reassess oxygen requirements every _____ hours □ Monitor for signs of respiratory fatigue or deterioration
Disposition
Decision:
□ Discharge home □ Admit to: □ Regular floor □ Step-down unit □ ICU □ Transfer to: _____ □ Palliative care consultation
If Discharged:
□ Home oxygen assessment completed 3 □ Oxygen prescription: _____ L/min for _____ hours/day □ Follow-up appointment in _____ days/weeks □ Discharge medications: _____ □ Patient education provided on: _____ □ Return precautions discussed
If Admitted:
□ Reason for admission: _____ □ Primary team: _____ □ Consultations: _____ □ Goals of care discussed: □ Yes □ No
Clinical Decision Making
Assessment: _____ Plan: _____
Physician Signature: _____________________ Date/Time: _____