For respiratory therapists preparing for the Therapist Multiple-Choice (TMC) and Clinical Simulation Exam (CSE), mastering the interpretation of the medical record is crucial for clinical decision-making and improving patient outcomes.
Key sections of the medical record—such as provider orders, patient history, physical exam findings, lab results, and imaging studies—help guide RTs in evaluating patient conditions and implementing appropriate respiratory care strategies.
Understanding how to synthesize this information during the exam can significantly enhance performance in areas like data evaluation and clinical case simulations.
Take our free course to learn essential tips, insights, and strategies to pass the TMC Exam on your first (or next) attempt.
Understanding the Patient Medical Record
The patient medical record is a vital tool for respiratory therapists, both during clinical practice and when preparing for board exams. These records provide a detailed snapshot of a patient’s health status, including their history, diagnostic results, treatments, and progress.
For exam candidates, mastering the ability to analyze patient records is essential, as questions on both the TMC and CSE often require interpreting this data to make informed clinical decisions.
Watch this video and keep reading to learn more about patient medical records and what you must know for the TMC/CSE exams.
Key Components of the Patient Medical Record
The medical record contains multiple sections, each offering unique insights into a patient’s condition. Here is a breakdown of the most relevant sections for respiratory therapists:
Provider Orders
This section lists diagnostic and therapeutic instructions from authorized providers, such as physicians or physician assistants. Respiratory therapists must be able to interpret orders for treatments like oxygen therapy, mechanical ventilation settings, and medication dosages.
Understanding the importance of verifying complete and accurate orders is essential, particularly when they relate to respiratory interventions.
Note: Be cautious of vague orders, such as “continue previous settings,” which require clarification.
Patient History
The history provides background information about the patient, including past illnesses, surgeries, medications, and family history of respiratory conditions. Social history, such as smoking habits or exposure to environmental toxins, can also reveal important factors contributing to respiratory issues.
Note: Exam questions may ask you to assess patient risk factors based on their history or recommend appropriate next steps for managing chronic conditions like COPD or asthma.
Physical Examination Findings
The physical exam section contains observations related to the patient’s appearance, vital signs, and respiratory status. Key findings include inspection of chest movement, presence of accessory muscle use, and auscultation of breath sounds.
Recognizing abnormal patterns such as crackles, wheezing, or diminished breath sounds can help narrow down potential diagnoses.
Take our free course to learn essential tips, insights, and strategies to pass the Clinical Simulation Exam (CSE) on your first (or next) attempt.
Laboratory Test Results
Laboratory data, particularly blood gas analysis and hematology results, play a significant role in respiratory care. Common lab tests include arterial blood gases (ABGs), which provide information about a patient’s oxygenation, ventilation, and acid-base status.
Other important lab values include white blood cell (WBC) counts, which indicate infection, and hemoglobin levels, which affect oxygen-carrying capacity.
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
- BE (Base Excess): ±2
CSE Application: You may encounter scenarios where the patient presents with abnormal ABG values, such as respiratory acidosis (low pH, high PaCO₂). You’ll need to determine appropriate interventions, such as adjusting ventilator settings or initiating non-invasive ventilation (NIV).
Imaging Studies
Chest x-rays (CXR) are the most common imaging studies encountered in respiratory care. They provide critical information about lung structure and function. Key findings may include infiltrates (suggestive of pneumonia), hyperinflation (seen in COPD), and pleural effusions (fluid buildup in the pleural space).
Other imaging modalities, such as computed tomography (CT) scans, may be used to diagnose conditions like pulmonary embolism or interstitial lung disease.
TMC Exam Tip: When reviewing a chest x-ray, look for classic signs such as the “steeple sign” (indicative of croup) or “white-out” appearance (associated with acute respiratory distress syndrome). Expect to identify abnormal radiographic findings in both multiple-choice and case-based questions.
Trends in Vital Signs and Monitoring Data
Beyond individual readings, trends in vital signs and non-invasive monitoring values provide insight into the progression or improvement of a patient’s condition.
Key trends to monitor include:
- Heart rate and respiratory rate changes indicating distress or recovery
- SpO₂ levels, which assess the patient’s oxygenation status
- End-tidal CO₂ (EtCO₂) values, which reflect ventilation effectiveness
Note: Monitoring trends can also reveal the effectiveness of interventions, such as improvements in oxygen saturation following adjustments to therapy.
Synthesizing Medical Record Data for Decision-Making
The CSE in particular emphasizes decision-making based on medical record interpretation. This involves:
- Information Gathering (IG): Identifying relevant details from the patient record, such as worsening ABG trends or lab test abnormalities.
- Decision Making (DM): Applying the gathered information to make informed choices, such as initiating bronchodilator therapy for an asthma exacerbation or recommending intubation for worsening respiratory failure.
Note: To succeed, practice recognizing when data trends indicate a need for immediate action versus ongoing monitoring.
Advanced Directives and Do-Not-Resuscitate (DNR) Orders
This section of the medical record contains crucial information about a patient’s wishes regarding life-sustaining treatments, particularly in cases of respiratory failure or cardiac arrest.
Advanced directives may include:
- Living Will: Specifies the types of medical interventions the patient consents to or declines in the event they become incapacitated.
- Durable Power of Attorney (DPOA): Designates a person to make medical decisions on the patient’s behalf if they are unable to do so.
- DNR/DNI Orders: Indicate whether the patient declines resuscitation (DNR) or intubation (DNI).
Example Scenario: You may be presented with a patient in respiratory arrest who has a documented DNR order. In this case, you must respect the patient’s wishes while ensuring comfort measures are in place, such as providing supplemental oxygen via non-invasive methods.
Progress Notes and Interdisciplinary Documentation
Progress notes from physicians, respiratory therapists, nurses, and other healthcare team members offer insights into how the patient is responding to care over time. These notes may highlight changes in clinical status, therapeutic adjustments, and plans for ongoing management.
They also include subjective observations, such as reports of increased work of breathing or a patient’s level of comfort.
TMC Exam Tip: Exam questions may ask you to interpret progress notes to determine the next appropriate step in care, such as transitioning a patient from mechanical ventilation to a spontaneous breathing trial based on documented progress.
Strategies for Success When Evaluating Patient Records
- Practice Active Reading: When reviewing exam scenarios involving patient records, underline key findings such as abnormal lab results, changes in medication, or provider recommendations.
- Identify Patterns: Look for trends in data rather than isolated values. For example, a gradual increase in PaCO₂ levels over several ABG samples may indicate impending respiratory failure.
- Use Clinical Context: Consider the patient’s diagnosis and current condition when interpreting data. For instance, a normal PaO₂ for a patient on supplemental oxygen may still indicate hypoxemia if they are on a high FiO₂.
Integrating Study Resources for Exam Preparation
Preparing for the TMC and CSE exams requires more than memorization—it requires the ability to apply knowledge to real-world clinical situations.
To strengthen your ability to evaluate patient records:
- TMC Test Bank: Practice interpreting patient scenarios with over 640 premium questions designed to mimic real exam questions.
- TMC Exam Hacks: Watch strategy-focused videos that break down key exam topics, including patient data evaluation.
- Daily Practice Questions: Reinforce your skills daily by reviewing practice questions on various topics, such as ABG interpretations, lab results, imaging studies, and more.
- CSE Boost Course: Build confidence in your decision-making abilities through simulation-based learning to prepare for the unique exam format.
Note: By dedicating time to mastering the components of the patient medical record and practicing with real-life scenarios, you’ll be better prepared to handle the complexities of the TMC and CSE exams—and ultimately provide high-quality, evidence-based respiratory care.
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Final Thoughts
A solid grasp of a patient’s medical record is vital for success on the TMC and CSE exams. It enables respiratory therapists to interpret clinical data, assess trends, and apply patient-centered interventions effectively.
By familiarizing themselves with the structure and content of medical records, including provider orders, lab tests, and diagnostic reports, exam candidates can approach questions with confidence.
Integrating this knowledge with strategic exam preparation tools, such as practice questions and review courses, will not only improve exam scores but also prepare students for real-world scenarios where patient records are the foundation of high-quality respiratory care.
Written by:
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
References
- Registered Respiratory Therapist (RRT). The National Board for Respiratory Care. 2025.