What is the proper method for documenting examination findings in a respiratory system examination?

Documentation of Respiratory System Examination Findings

Document respiratory examination findings in a standardized format that includes patient demographics, test conditions, measured values with reference ranges, quality indicators, and graphical displays of all acceptable maneuvers. 1

Essential Patient Information

Begin every respiratory examination report with unambiguous patient identification:

• Patient name, medical record number, sex, and date of birth 1
• Height (to nearest centimeter), weight (in kg to 3 significant digits), and ethnicity 1
• Date and time of test, test duration 1
• Smoking history, reason for test, referring physician name 1
• Oxygen saturation and barometric pressure 1

The date of birth serves as a verification check against previous records to prevent identification errors 1. For children and adolescents, calculate age to one decimal place (e.g., 6.3 years) 1.

Structured Presentation of Measured Values

Organize all measured parameters in a standardized tabular format with columns for: Best Value, Lower Limit of Normal (LLN), Upper Limit of Normal (ULN), z-score, and % Predicted. 1

• Display values in physiologically rational order (e.g., VC, IC, FEV1/VC for slow vital capacity measurements) 1
• Report all values to at least 3 effective digits 1
• Include the reference equation source used for predicted values 1
• For spirometry, report FEV1, FVC, FEV1/FVC ratio, and forced expiratory time (FET) 1
• Document peak expiratory flow (PEF) and respiratory rate during measurements 1

The LLN should be shown at a z-score of -1.64 on linear graphics divided in units of 1 standard deviation 1.

Quality Assessment Documentation

Include explicit quality indicators for every examination to allow proper interpretation of results:

• Document extrapolated volume (EV) - must be <5% of FVC or 0.150 L, whichever is greater 1, 2
• Record number of acceptable maneuvers performed 1
• State reproducibility criteria met: difference between two largest FVC values ≤0.150 L and two largest FEV1 values ≤0.150 L 1, 2, 3
• For FVC ≤1.0 L, both values must be ≤0.100 L 2
• Document coefficient of variation for repeated measurements 1
• Note test position (sitting preferred, with chair having arms and no wheels) 1, 2
• Record whether nose clip was used 1, 2

Quality grading helps referring physicians understand data reliability without excluding results from reports 2.

Graphical Display Requirements

Preserve and display volume-time and/or flow-volume curves from at least the three best maneuvers. 1, 2

• Show the complete preceding inspiratory maneuver, including at least 1 second prior to exhalation start 1
• Display back-extrapolation method used to determine time zero 1
• For diffusing capacity, graph CO and tracer gas concentrations versus exhaled volume 1
• For nitrogen washout, plot on log scale to show nearly linear profile 1
• Include sample volume and note if values were corrected to standard barometric pressure 1

The flow-volume curve should demonstrate rapid, sharp rise with PEF occurring close to maximal inflation point 1, 2.

Test-Specific Documentation Elements

For spirometry with bronchodilator testing:

• Report absolute and percent change only for FEV1 and FVC 1
• LLN column need not be repeated for post-bronchodilator values 1

For diffusing capacity (DLCO):

• Show hemoglobin value with adjusted predicted values for both DLCO and KCO 1
• Report alveolar volume (VA), thoracic gas volume (TLC), and VI/VC ratio 1
• Document test quality grade and barometric pressure 1

For lung volume measurements:

• Display results from body plethysmography or gas dilution with same column order 1
• Show RV, FRC, and TLC with arrows indicating position relative to normal range 1

Data Storage and Accessibility

Store comprehensive data to enable subsequent review and reanalysis:

• Save calibrated raw data allowing original test display and reanalysis 1
• Document prevailing measurement conditions, test duration, and any interruptions 1
• Record total number of trials performed and results of individual trials 1
• Store technically satisfactory data even if they are outliers 1
• Include operator comments regarding individual measurements 1
• Save all relevant information including biometric data, analysis options, calibrations, filters, and sampling rate 1

Enable export of results in standard spreadsheet, database, or ASCII format 1.

Common Pitfalls to Avoid

Do not use boldface or colored fonts to highlight values below LLN, as this imposes binary decisions on continuous variables and may lead to false positive interpretations 1. Avoid reporting excessive numbers of parameters, which increases statistical likelihood of false positives 1.

Discard maneuvers with unacceptable start or cough before applying reproducibility criteria, but do not exclude results from reports based solely on failure to meet reproducibility criteria - instead use this to indicate data quality 1, 2.

For children, document special considerations: create age-appropriate testing environment, provide detailed but simple instructions with visual feedback, and note that some young children may have difficulty meeting end-of-test criteria despite meeting other reproducibility standards 1, 2.