University Of Michigan Spirometry Encounter Form
ADVERTISEMENT
1Spirometry Encounter Form
Today’s Date: _________________
Person Performing Test: __________________________
Patient’s Name: _______________________________ Height: ______________
inches
cm.
MRN #: _________________ Race: _________________ Weight: ______________
lbs.
kgs.
Date of Birth: _____/______/______
Smoking Status:
Never
Ever Used
Current
Diagnosis:
Asthma
COPD
Other: _____________________________________________
Patient’s Last Use of a Short-action Inhaler or Nebulizer (i.e. Albuterol, ProAir, Proventil, Ventolin, Maxair):
______________________
Gender at birth:
Male
Female
Patient’s Posture During Test:
Standing
Sitting
Nose Clips Used:
Yes
No
Number of Trials: _____________________
ACCEPTABILITY CRITERIA:
REPEATABILITY CRITERIA:
select all
select all that apply
that apply
The two largest FEV1 values within 0.15L AND the
Free from Artifacts
two largest FVC values within 0.20L
Good Start
Total of EIGHT tests performed
Satisfactory Exhalation
The patient CAN NOT or SHOULD NOT continue
NOT Satisfactory
The Patient Demonstrated:
Good Effort
Difficulty following instructions
Ability to obtain only one good effort
Poor Effort
Cooperation
Other: __________________________________________________
Comments:
The information in this reference was reviewed by the UMHS Asthma Quality Improvement Steering
Committee and the COPD Quality Improvement Steering Committee and was last updated on 5/23/12
Questions and/or comments may be directed to Karla Stoermer-Grossman, MSA, RN, AE-C
(kstoerme@umich.edu)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical