For Respiratory Therapists ·
What you'll accomplish
Otter.ai on your phone captures voice notes immediately after each assessment and auto-transcribes them to text, ready to paste directly into Epic or Cerner. Instead of batch-charting 12 patients from memory at shift's end, you'll have timestamped notes building throughout the day.
What you'll need
Important HIPAA note: Do NOT say patient names, MRNs, or other direct identifiers in your voice notes. Use room numbers, initials, or case numbers. Otter.ai stores transcripts on their servers. This is equivalent to writing notes in a personal notebook, not a HIPAA-covered system. Your institution may have specific guidance on this. Check with compliance if uncertain.
What you should see: The Otter.ai home screen with your empty transcript list and a big orange microphone button.
Troubleshooting: If the app asks for microphone permission, tap Allow. This is required for transcription to work.
Before your shift, record a test note to practice the format. Tap the orange record button, then say:
"Room [number], [time], vent check. Settings: AC/VC, rate [x], tidal volume [x], PEEP [x], FiO2 [x] percent. Patient SpO2 [x] on current settings. Breath sounds [description]. No vent alarms. Patient [awake and following commands / sedated / agitated]. Plan: continue current settings, wean FiO2 to [x] if SpO2 remains above 94."
Tap stop (the orange square). Watch Otter transcribe it within 5-10 seconds.
What you should see: Your spoken words appear as formatted text in the transcript view, with timestamps.
Troubleshooting: If transcription is slow or inaccurate, make sure you're speaking clearly at a moderate pace, and hold the phone 6-12 inches from your mouth (or use earbuds with a microphone).
This makes it fast enough to use in a busy hallway. You're not navigating menus between patients.
Use Otter during the shift, then transfer to EHR:
Use these voice templates for common RT tasks:
Ventilator check:
Room [number], [time], vent check. Mode [mode], rate [x], TV [x]mL, PEEP [x], FiO2 [x]%. SpO2 [x]%. Breath sounds: [description]. No patient-vent dyssynchrony. [Any change made and rationale].
ABG result relay note:
Room [number], [time], ABG result: pH [x], PaCO2 [x], HCO3 [x], PaO2 [x] on FiO2 [x]%. Interpretation: [summary]. Relayed to [physician name/role] at [time]. Orders received: [what changed].
Extubation note:
Room [number], [time], patient extubated following successful SBT. Duration [x] minutes. Extubation tolerated well. Post-extubation SpO2 [x]% on [supplemental O2]. Breath sounds: [description]. Patient [vocalization or verbal response]. Will reassess in [x] hours.
Treatment refusal:
Room [number], [time], patient declined [treatment]. Reason given: [patient statement]. Education provided regarding importance of treatment. Patient verbalized understanding. Physician notified at [time].