Recordkeeping, Reporting, and Communication of Results
Recordkeeping, Reporting, and Communication of Results
This domain tests what must be recorded, how long it is kept, and how results are communicated without overstepping.
Core rules
- Record demographics, height, weight, ethnicity, test date, medications, and bronchodilator timing.
- Include the flow-volume and volume-time curves, predicted values and LLN, the largest FVC and FEV1, and the acceptability/reproducibility grade.
- Document technical problems, participant effort, and any reason a test was deferred.
- Retain records according to applicable rules: OSHA respiratory medical records for the duration of employment plus 30 years; exposure records for 30 years.
- Report to the responsible physician or program; give the participant a clear, non-diagnostic explanation and refer abnormal findings.
- Protect confidentiality and share only the minimum necessary.
Worked example
A technician obtains a grade B session with FEV1/FVC below LLN. Reasoning: grade B is usable, but the report must state the grade, include the curves, and note that the pattern suggests obstruction; it should not state a diagnosis. The physician interprets and communicates the final result.
Traps
- Reporting only numbers without curves or quality grade.
- Discarding deferred or unacceptable tests instead of documenting them.
- Telling a participant they have COPD based on spirometry alone.