Office Spirometry Procedure/Interpretation Report

Patient: [Full name]; MRN: [Medical record number]; DOB: [YYYY-MM-DD]; Age: [Age in years]

Test Date/Time: [YYYY-MM-DD HH:MM]

Location: [Clinic/facility name]

Test Type: [Spirometry (pre-bronchodilator only) / Spirometry with bronchodilator responsiveness testing (pre/post)]

Reference Equations: [Reference set used (e.g., GLI-2012, NHANES III)]; LLN/z-scores: [applied / not applied]

Performing Personnel: [Name, credentials]

Interpreting Clinician: [Name, credentials]

Ordering Clinician: [Name, credentials] (Include only if different from interpreting clinician; otherwise omit.)

Clinical Indication

[Brief indication for testing including primary reason (e.g., dyspnea, cough, suspected asthma/COPD, monitoring known disease, pre-operative evaluation) and relevant context affecting interpretation such as smoking history, recent respiratory infection, or current inhaler therapy.] (Include only if explicitly documented; otherwise omit this section entirely.)

Pre-Test Context

[Relevant preparation details: bronchodilator withholding status and timing of last use, deviations from standard preparation (e.g., recent smoking, vigorous exercise), relative contraindications screened, symptoms during testing prompting early termination.] (Include only when relevant information is available; do not infer withholding or screening if not documented; otherwise omit this section entirely.)

Procedure

[Concise description including patient position (seated/standing), nose clip use (yes/no), number of maneuvers attempted, and coaching/effort adequacy. If bronchodilator testing performed, include agent, total dose, delivery device (MDI with spacer / nebulized), wait time before post-testing, and any adverse effects.]

Test Quality

• Session Quality Grade: Pre: [A / B / C / D / E / F]; Post: [A / B / C / D / E / F] (Include Post grade only if post-bronchodilator testing performed; note if interpreter grade differs from device-generated grade.)
• Acceptability/Repeatability: ≥3 acceptable maneuvers: [yes / no]; Repeatability met for FEV1: [yes / no]; Repeatability met for FVC: [yes / no]; Primary reason if criteria not met: [cough in first second / early termination / poor start / variable effort / leak / other]
• Limitations: [Brief statement of limitation and impact on interpretation, e.g., "Interpretation limited by suboptimal repeatability; values may underestimate true lung function."] (Include only when quality is suboptimal. If no acceptable efforts obtained, state "Test uninterpretable" and omit physiologic interpretation below.)

Results

(Reported FEV1 and FVC represent the largest acceptable values; the FEV1/FVC ratio is calculated from those values even if from different maneuvers.)

Pre-bronchodilator

• FEV1 (L): Measured: [value]; Predicted: [value]; LLN: [value]; z-score: [value]; % predicted: [value]
• FVC (L): Measured: [value]; Predicted: [value]; LLN: [value]; z-score: [value]; % predicted: [value]
• FEV1/FVC: Measured: [value]; LLN: [value]; z-score: [value]
• Optional parameters: [PEF, FET, FEV6 with values if clinically useful] (Omit if not clinically relevant. If FEF25-75 included, note high variability.)

Post-bronchodilator

(Include only if post-bronchodilator testing performed; otherwise omit.)

• FEV1 (L): Measured: [value]; Predicted: [value]; LLN: [value]; z-score: [value]; % predicted: [value]
• FVC (L): Measured: [value]; Predicted: [value]; LLN: [value]; z-score: [value]; % predicted: [value]
• FEV1/FVC: Measured: [value]; LLN: [value]; z-score: [value]

Bronchodilator Response

(Include only if post-bronchodilator testing performed; otherwise omit.)

• Δ FEV1: [absolute change in L]; [change as % of predicted]
• Δ FVC: [absolute change in L]; [change as % of predicted]
• Meets positivity criterion: [yes / no]; Criterion used: [>10% of predicted / ≥12% and ≥200 mL / other]

Interpretation

• Interpretive Method: [Framework used, e.g., "Interpretation based on LLN (z < -1.645) using GLI-2012 reference equations."]
• Ventilatory Pattern: [Normal spirometry / Obstructive ventilatory impairment / Possible restrictive pattern (confirm with lung volumes) / Mixed pattern possible (confirm with lung volumes) / Non-specific or PRISm pattern] (If FVC reduced with obstruction, note need to distinguish air trapping from true restriction. Do not confirm restriction without TLC.)
• Severity: [Physiologic severity using z-score categories]; [Disease-specific staging (e.g., GOLD) if applicable, labeled separately]
• Bronchodilator Response: [Positive / Negative] in [FEV1 / FVC / both]; [brief clinical correlation statement] (Include only if post-bronchodilator testing performed.)
• Comparison to Prior: [Change in FEV1 and FVC compared to prior testing with clinical significance] (Include only when comparable prior spirometry available; avoid comparing % predicted if reference equations changed.)

Clinical Correlation

[Actionable correlation with clinical context; recommendations for further testing if appropriate (e.g., full PFTs with lung volumes/DLCO if restriction suspected, repeat spirometry if quality inadequate); documented management actions taken.] (Optional section; include only when clinically relevant; limit to 2-4 brief statements; do not infer actions not explicitly documented.)

Attestation

I have reviewed the spirometry results, including quality indicators and graphics, and provided the above interpretation.

Signature: [Interpreting clinician signature]

Credentials: [Credentials]

Date/Time Signed: [YYYY-MM-DD HH:MM]

Attachments

[Flow-volume loop and volume-time curves: attached / stored in EHR media library at specified location] (Retain graphics with report when interpretation depends on identifying artifacts.)

(Meta-instructions: Patient identifiers, test date/time, interpreter identity, core results (FEV1, FVC, FEV1/FVC), quality statement, and attestation are always required. Omit optional sections entirely when information is unavailable rather than including empty placeholders. Do not infer bronchodilator withholding, contraindication screening, or confirmed restriction without documented lung volumes.)