Healthcare Pulmonary Specification

HEALTHCARE PULMONARY SPECIFICATION

This Pulmonary Specification documents the clinical indication, procedural details, patient-specific considerations, risks, and authorizations required to perform pulmonary diagnostic testing and related procedures. The information provided below will be used to plan and conduct testing consistent with current clinical standards and patient safety requirements.

Patient Information

Date of Birth:    Gender:    MRN/ID:

Insurance / Authorization

Clinical Indication & Requested Procedures

Ordering Provider:    Clinic/Hospital:

Spirometry (including FEV1, FVC)    Full Pulmonary Function Testing (includes lung volumes)    DLCO (diffusing capacity)    Bronchodilator challenge    Exercise testing    Other:

Medical History & Current Status

Asthma    COPD    Interstitial lung disease    Sleep apnea    Other:

Smoking Status:    Home Oxygen Use:

Pre-Test Precautions & Contraindications

Contraindications or special precautions that may affect testing (check all that apply):

Active respiratory infection    Recent myocardial infarction (within 1 month)    Recent eye/abdominal/thoracic surgery    Pregnant    Hemoptysis    Inability to perform reproducible maneuvers

Short-acting bronchodilators: Withhold for days.   Long-acting bronchodilators: Withhold for days.

Other medication instructions:

Examination Data / Baseline Measurements

Risks, Benefits, and Alternatives

The patient has been informed that pulmonary function testing is generally safe and provides diagnostic information to guide care. Known risks include transient lightheadedness, coughing, bronchospasm, syncope, transient chest discomfort, and, rarely, cardiac events. For bronchoprovocation or exercise testing, additional specific risks include induced bronchospasm and cardiovascular stress. The alternative to testing is clinical management without objective pulmonary physiologic data, which may limit diagnostic accuracy.

Patient Authorization and Privacy Acknowledgment

By signing below, I authorize the performance of the indicated pulmonary diagnostic procedures and acknowledge that the nature, purpose, potential benefits, and risks of the procedures have been explained to me in terms I understand. I acknowledge that I have had the opportunity to ask questions and that all my questions have been answered to my satisfaction.

I acknowledge receipt of the facility's notice of privacy practices describing the use and disclosure of protected health information for treatment, payment, and health care operations. I authorize release of test results to the ordering provider and other health care professionals involved in my care for the purpose of diagnosis and treatment.

I have read and understand the above statements and consent to the testing and release of results as described.

Ordering Provider Certification

I certify that the information provided above is accurate to the best of my knowledge and that the indicated testing is medically necessary for the diagnosis or management of the patient's condition.

Sign Now