Six-Minute Walk Test Report

(Global meta-instructions: Use square-bracket placeholders to insert content. Keep objective measurements separate from interpretation. Never silently omit clinically or billing-critical missing values—use explicit "Not obtained—[reason]" statements. If multiple trials are performed in one session, label each trial clearly and replicate Test Performance and Results subsections per trial.)

Patient: [Name] | [MRN] | [DOB] | [Age] | [Sex]

Test Date/Time: [Date] at [Start time]

Location: [Outpatient clinic / PFT lab / Inpatient / Rehab gym / Other: specify]

Ordering Clinician: [Name, credentials]

Performing Staff: [Name(s), credentials (RT/RN/EP/etc.)]

Indication(s): (Mark all that apply) Functional exercise capacity assessment Exertional desaturation assessment Ambulatory oxygen qualification Oxygen titration Pre/post intervention comparison Prognostic/baseline assessment Other: [specify]

Relevant Diagnoses: [Brief problem list]

Comparison Study: [Prior 6MWT date] — [Distance], [Nadir SpO2], [O2 device/flow]; Conditions comparable: [Yes/No and key differences] (If none available, state "None available.")

Protocol / Methodology

Test Type: [Standard 6MWT (distance primary) / 6MWT for oxygen assessment / Modified walk or oxygen titration: specify modification] (If multiple trials performed, label as Trial 1, Trial 2, etc.)

Course: [Straight corridor / Track / Treadmill / Other] | Length: [m] | Turnaround: [cones / lines / other] (Note any deviations from standard corridor with reason.)

Monitoring: Pulse oximetry: [Continuous / Intermittent]; Sensor site: [Finger / Forehead / Earlobe]; HR measurement: [Pulse ox / ECG / Manual]; Symptom scale: [Borg 0–10 / Other]

Standardization:

• Pre-test rest period: [Yes/No]; Duration: [minutes]
• Standardized instructions provided: [Yes/No]
• Standardized encouragement given: [Yes/No]
• Assessor pacing occurred: [Yes/No] (Should be No; if Yes, explain)
• Practice test performed: [Yes/No] (If Yes, specify which trial is reported)

Oxygen and Mobility Aids:

• Oxygen at rest: [Room air / Device + flow + mode]
• Oxygen during walk: [Room air / Device + flow + mode]; Carried by: [Patient / Staff]
• Walking aid: [None / Cane / Walker / Rollator / Other]
• Differences from prior test: [Specify or "None"]

Deviations/Limitations: [List any protocol deviations, equipment issues, or factors affecting validity; state "None" if none]

Pre-Test Status

Contraindication Screen: [Completed per local policy; no contraindications identified / Relative contraindications present: specify, authorized by: name]

Baseline Measurements:

Parameter	Value
SpO2 (%)	[%]
HR (bpm)	[bpm]
BP (mmHg)	[mmHg / Not obtained—reason]
Borg Dyspnea (0–10)	[score]
Borg Leg Fatigue (0–10)	[score]

Baseline Symptoms: [None / Dyspnea / Chest pain / Dizziness / Leg pain / Fatigue: briefly describe if present]

Test Performance

Completion Status: [Completed full 6 minutes / Not completed: Stop time mm:ss, Total stopped time mm:ss, Number of stops #, Resumed Yes/No, Reason(s): Dyspnea / Leg fatigue / Chest pain / Dizziness / Desaturation / Other]

Adverse Events/Interventions: [None / Describe concerning signs and interventions: seated rest, bronchodilator, oxygen applied, test terminated]

Event Log: (Optional; recommended for oxygen titration or significant desaturation. Add rows as needed.)

Timestamp	SpO2 (%)	HR (bpm)	O2 Flow	Borg Dyspnea	Notes
[mm:ss]	[%]	[bpm]	[L/min]	[score]	[Brief note]
[mm:ss]	[%]	[bpm]	[L/min]	[score]	[Brief note]

Results

Distance: Total: [meters]; Laps: [#] + [partial lap m]; Average speed: [m/min] (If test incomplete, document distance at stop and total walking time.)

Oxygenation:

Metric	Value
Baseline SpO2	[%]
Nadir SpO2	[%] at [mm:ss]
End-test SpO2	[%]
Change from baseline	[Δ%]
Time below threshold	[Duration] below [threshold %] (If available)

Cardiovascular:

Metric	Value
Baseline HR	[bpm]
Peak/End-test HR	[bpm]
Recovery HR	[bpm] at [timepoint] / Not measured
Post-test BP	[mmHg / Not obtained] (Include if abnormal or symptomatic)

Symptoms: Borg Dyspnea: [baseline → end-test]; Borg Leg Fatigue: [baseline → end-test]. Other: [ ] Chest pain [ ] Dizziness [ ] Near-syncope [ ] Wheeze [ ] Claudication [ ] Musculoskeletal pain [ ] Other: [specify]

Recovery: (If measured) At [timepoint]: SpO2 [%]; HR [bpm]; [Delayed symptoms / ongoing oxygen needs / None]

Oxygen Assessment / Titration

(Include this section only when oxygen qualification or titration was an indication.)

Purpose: [Qualification documentation for ambulatory oxygen / Clinical titration for exertional hypoxemia / Both]

Target: Saturation goal: [≥90% / ≥88% / Other]; Achieved: [Yes/No]

Study A (Rest, Room Air): SpO2: [%]; HR: [bpm]; Signal quality: [Adequate / Inadequate]

Study B (Exercise, Room Air): Nadir SpO2: [%] at [mm:ss]; Symptoms: [specify]; Distance/time: [m] in [mm:ss]

Study C (Exercise with Oxygen): Device/flow/mode: [specify]; Nadir SpO2: [%] at [mm:ss]; Improved vs Study B: [Yes/No]; Final settings: [device/flow/mode]

(If any study not performed, state which and why: Unsafe on room air / Cannot remove chronic oxygen per order / Other)

Titration Progression: Flow sequence: [e.g., 2→4→6 L/min with timestamps]; Delivery mode: [NC / Mask; Continuous / Pulse-dose; POC / Cylinder]; Maximum tested: [L/min]; Stopped because: [Target achieved / Symptom-limited / Equipment limit / Safety stop]

Summary Statement: During exertion on room air, SpO2 decreased to [nadir %] at [mm:ss]. With supplemental oxygen at [device/flow], exertional SpO2 nadir was [%]. Findings [support / do not support] need for ambulatory oxygen during exertion. (Do not infer qualification without documented room air and on-oxygen exertional SpO2 values.)

Interpretation

Functional Capacity: [Normal / Mildly reduced / Moderately reduced / Severely reduced]. Basis: [Percent predicted / Comparison to prior / Diagnosis-specific expectations]. Percent predicted: [%] using [reference equation] (Omit if demographics outside validated ranges.)

Exertional Desaturation: [Present / Absent]. Definition: [e.g., drop ≥4% to <90%]. Signal quality: [Adequate / Inadequate]. (If severe desaturation or stop criteria reached, state safety actions taken.)

Longitudinal Change: (If comparison study available) Compared with [date]: [Summarize change in distance and nadir SpO2]. Conditions comparable: [Yes/No]; Differences: [specify]. (State comparison is limited if conditions differed materially.)

Limitations: [Methodology differences, incomplete data, signal quality issues affecting interpretation / None]

Impression

• 6MWD: [distance m] ([% predicted if valid]); [Completed / Not completed]; Stops: [#]
• Oxygenation: [Baseline %] → [Nadir % at mm:ss] → [End %]; Desaturation: [Present / Absent]
• Limiting Symptom(s): [Primary limitation]
• Oxygen Titration: (If performed) [Final exertional setting] — [one-line response summary]
• Test Quality/Limitations: [Factors affecting validity or comparability / None]

Recommendations

(Include only recommendations supported by documented objective data. Do not assert payer coverage eligibility.)

• [Ambulatory oxygen: exertion-only vs continuous; device/flow range; rationale tied to measured desaturation]
• [Pulmonary rehabilitation: new referral or continuation based on documented functional limitation]
• [Further evaluation: PFTs, imaging, echocardiography, CPET if desaturation disproportionate to known disease]
• [Safety considerations: fall risk, severe desaturation requiring supervised exercise, other precautions]

Signature

Interpreter: [Name, credentials]

Date/Time of Interpretation: [Date] at [Time]

Attestation: 6MWT performed in accordance with standardized protocol. Deviations: [List / None]. (If oxygen qualification intended: Studies A–C documented as described, or limitations noted.)