Patient Medical Record Tips for the Board Exam (2026)

The patient medical record is one of the most critical tools in respiratory care. It serves as a centralized, organized collection of clinical information that documents a patient’s health history, diagnostic data, treatment plans, and response to therapy over time. In daily clinical practice, respiratory therapists rely on the medical record to guide safe and effective care. On the board exams, it becomes the foundation for nearly every clinical decision you are expected to make.

For respiratory therapy students preparing for the Therapist Multiple-Choice (TMC) exam and the Clinical Simulation Exam (CSE), mastering the interpretation of the patient medical record is essential. Many exam questions are designed to test your ability to analyze chart data, recognize clinical patterns, and determine the most appropriate next step in patient management.

Key sections of the medical record include provider orders, patient history, physical examination findings, laboratory results, imaging studies, and monitoring trends. These sections work together to create a complete clinical picture. Understanding how to synthesize this information efficiently is especially important for success on the CSE, where decision-making is based almost entirely on the patient record.

Developing strong medical record interpretation skills not only improves exam performance, but also prepares you for real-world practice, where timely and accurate clinical decisions can directly impact patient outcomes.

Understanding the Patient Medical Record

The patient medical record is a detailed and continuously updated documentation of a patient’s healthcare experience. It includes objective data, subjective reports, provider assessments, diagnostic findings, and treatment plans from multiple members of the healthcare team.

For respiratory therapists, the medical record is essential for understanding a patient’s respiratory status, identifying underlying disease processes, and evaluating the effectiveness of current therapies. On the board exams, it serves a similar purpose. You are expected to use the information provided to determine what is happening physiologically and what intervention is required.

Both the TMC and CSE exams assess your ability to interpret medical record data rather than simply recall isolated facts. You must demonstrate that you can connect patient history, physical findings, lab values, and imaging results to make sound clinical judgments.

Key Components of the Patient Medical Record

The patient medical record is divided into multiple sections, each contributing unique information about the patient’s condition. As a respiratory therapist, you must know which sections are most relevant to respiratory care and how to interpret them quickly.

Watch this video and keep reading for a detailed review of the key components you should focus on when preparing for the board exam.

Provider Orders

Provider orders outline the diagnostic tests and therapeutic interventions authorized for the patient. These orders guide respiratory care and serve as the legal basis for initiating treatments.

Common respiratory-related orders include:

• Oxygen therapy device and flow rate or FiO₂
• Aerosolized medication schedules
• Mechanical ventilation mode and settings
• Non-invasive ventilation parameters
• Airway clearance techniques

On board exams, you may be asked to determine whether an order is appropriate, complete, and safe. In some scenarios, the correct answer involves recognizing that an order is unclear or incomplete and requires clarification before proceeding.

Note: Be cautious of vague orders such as “continue previous settings” or “oxygen as needed.” These often indicate that additional assessment or clarification is required.

Patient History

The patient history section provides critical background information that helps explain the patient’s current respiratory condition. This includes both past and present health information.

Important elements of patient history include:

• Previous respiratory diagnoses
• Cardiac or neuromuscular conditions
• Medication history
• Smoking status and occupational exposures
• Recent hospitalizations or infections

Patient history often provides key clues that guide clinical decision-making. For example, a history of COPD may explain chronic hypercapnia, while a history of asthma may suggest bronchospasm as the cause of acute distress.

Note: Exam questions frequently require you to identify risk factors or recommend appropriate management strategies based on patient history, especially for chronic diseases such as COPD or asthma.

Physical Examination Findings

The physical examination section documents objective findings obtained during patient assessment. This information is essential for evaluating respiratory status and identifying signs of deterioration.

Key respiratory-focused findings include:

• Respiratory rate and breathing pattern
• Use of accessory muscles or retractions
• Chest symmetry and expansion
• Breath sounds such as wheezes, crackles, or diminished airflow
• Skin color and level of consciousness

On the board exams, physical exam findings often point toward the underlying problem. Wheezing may indicate bronchoconstriction, crackles may suggest fluid or alveolar collapse, and diminished breath sounds may indicate pneumothorax or atelectasis.

Laboratory Test Results

Laboratory data plays a central role in respiratory care decision-making. Arterial blood gas analysis is one of the most heavily tested topics on both the TMC and CSE exams.

ABGs provide information about:

• Ventilation effectiveness
• Oxygenation status
• Acid-base balance

Other important lab values include hemoglobin levels, which affect oxygen transport, and white blood cell counts, which may indicate infection or inflammation.

Key ABG Values to Know:

• pH: 7.35–7.45
• PaCO₂: 35–45 mmHg
• PaO₂: 80–100 mmHg (on room air)
• HCO₃⁻: 22–26 mEq/L
• Base Excess (BE): ±2

CSE Application: You may encounter abnormal ABG patterns such as respiratory acidosis with hypoxemia. In these cases, you must determine whether the issue is related to ventilation, oxygenation, or both, and select the most appropriate intervention.

Imaging Studies

Chest imaging provides visual confirmation of many respiratory conditions. Chest x-rays are the most common imaging studies referenced on the board exams.

Common radiographic findings include:

• Infiltrates associated with pneumonia
• Hyperinflation seen in obstructive lung disease
• Atelectasis or lobar collapse
• Pleural effusions
• Diffuse bilateral opacities

Advanced imaging such as CT scans may be mentioned in scenarios involving pulmonary embolism or interstitial lung disease.

TMC Exam Tip: Pay attention to classic radiographic patterns such as the “steeple sign” (indicative of croup) or diffuse white-out patterns associated with ARDS. Expect to identify abnormal radiographic findings in both multiple-choice and simulation-based questions.

Trends in Vital Signs and Monitoring Data

Trends in monitoring data often provide more meaningful insight than isolated values. On the board exams, you are frequently asked to recognize worsening or improving trends.

Important parameters include:

• Respiratory rate changes
• Heart rate and blood pressure
• SpO₂ trends
• End-tidal CO₂ values

Note: Improvement in these trends following an intervention often confirms that your clinical decision was appropriate.

Synthesizing Medical Record Data for Decision-Making

The CSE emphasizes clinical reasoning and decision-making based on patient data. This requires integrating multiple sections of the medical record rather than focusing on a single value.

Key steps include:

• Information Gathering (IG): Identifying relevant findings from the chart
• Decision Making (DM): Selecting appropriate diagnostic or therapeutic interventions

Note: Successful candidates recognize when immediate action is required and when continued monitoring is appropriate.

Advance Directives and Do-Not-Resuscitate (DNR) Orders

Advance directives outline a patient’s wishes regarding life-sustaining treatment. This information is critical during emergencies involving respiratory failure or cardiac arrest.

Advance directives may include:

• Living Will
• Durable Power of Attorney (DPOA)
• DNR/DNI Orders

Example Scenario: If a patient in respiratory arrest has a valid DNR/DNI order, invasive airway management is not performed. Comfort measures and supportive care are prioritized.

Progress Notes and Interdisciplinary Documentation

Progress notes document changes in patient status and response to therapy over time. These notes may come from physicians, nurses, respiratory therapists, and other healthcare professionals.

They often guide decisions related to weaning, escalation of care, or discharge planning.

Exam Tip: You may be asked to determine the next appropriate step in care based on documented improvement or deterioration in progress notes.

Strategies for Success When Evaluating Patient Records

• Practice Active Reading: Identify abnormal values immediately
• Focus on Trends: Look for changes over time
• Apply Clinical Context: Interpret data based on diagnosis and therapy

Integrating Study Resources for Exam Preparation

To strengthen your ability to evaluate patient medical records:

• TMC Test Bank
• TMC Exam Hacks
• Daily Practice Questions
• CSE Boost Course

Note: Regular practice with realistic scenarios is one of the most effective ways to build confidence for the board exams.

Final Thoughts

A strong understanding of the patient medical record is essential for success on the TMC and CSE exams. These exams assess your ability to interpret clinical data, recognize patterns, and apply appropriate respiratory care interventions.

By developing familiarity with provider orders, patient history, physical exam findings, laboratory results, imaging studies, and progress notes, you can approach exam scenarios with confidence and clarity.

When combined with consistent practice and high-quality study resources, mastery of the patient medical record will not only improve exam performance but also prepare you to deliver safe, effective, and professional respiratory care in clinical practice.