Record keeping Copy

Record keeping

Adequate record keeping is a critical component of a good spirometry program. To improve the quality of spirometry testing programs there are three important record keeping components:

  1. Spirometry test reports
  2. Equipment maintenance records
  3. Personal training and evaluation records

Spirometry Test Reports:

Employers are required to ensure that medical records for each worker, including the spirometry test results, are maintained for at least 40 years following the end of employment. Spirometry test reports should include:

  1. Test date and time
  2. Worker’s name, identification number, age, height, sex, and race
  3. Spirometer used (e.g., type, serial number, etc.)
  4. Ambient air or spirometer temperature and barometric pressure
  5. Test posture used (sitting or standing)
  6. Source of reference values used (for predicted normal and LLN values)
  7. Test results from at least the three best curves, preferably from all recorded manoeuvres, with test sequence indicated
  8. Operator’s name or initials
  9. Operator comments on worker cooperation/effort or other aspects of the test session
  10. Flow-volume and volume-time curves for all saved efforts
  11. A measure of repeatability
  12. Date of last calibration check.

Equipment Maintenance Records

Since equipment maintenance records support the accuracy of the spirometry test results in the medical record, equipment records should be saved as noted here below. Availability of such records permits later troubleshooting of problematic spirometry test results, which is particularly important when conducting periodic spirometry testing. Equipment Maintenance Records for each spirometer should include:

  1. A quality control log which records calibration checks, routine maintenance, upgrades, repairs performed and the results, the date and time of each procedure, and the operator’s name. Some computerized spirometry systems store this information in a database. Reports generated during calibration checks should be saved indefinitely
  2. The model, serial number, and identification number of the spirometer, and dates and versions of computer software and hardware updates or changes. Store the manufacturer’s manuals, warranties, etc. with the quality control log

Personnel Training and Evaluation Records

Personnel qualifications should be documented and available for review. Personnel Training and Evaluation Records should include:

  1. Records of operator continuing education and results of evaluation and feedback to operators
  2. Certificates from completed approved spirometry training courses.

All calibration and spirometry results must be stored in such a way that retrieval of a worker’s results is possible and uncomplicated. Mostly this is done digitally.  For any spirometers that do not have functionality to upload results to a computer, paper copies must be kept. Results on thermal paper should be photocopied and the original attached to the copy as these will fade after a few years.