Advanced Diagnostics Solutions, Inc.
15283 Rester Dr, Brooksville, FL 34613
Phone: (352) 239-2810 | Web: www.DynamicDiagnostic.com
Pulse Oximetry Test: Summary Report
Patient Information
Referring/Ordering Physician
DME/HME Courier
Jane Sampleton
Insurance ID : 123456789A
DOB : 12/25/1905
Gender : Female
Pt. Report ID : 0031400
John Pepper
NPI # : 147258369
Address : 1234 Main Street
Phone : 2582589632
Fax : 2589637412
HME Demo Account
15283 Rester Drive
NPI # :
Phone : 3522932810
Fax : 3522749122
Study Date : 7/24/2012
Start Time :
End Time :
Test Duration : 07:52:52
Excluded Time : 00:10:40
Valid Time : 07:43:12
Oximeter SN : 102607197
Device Type:920 Stan. R/N
Test Condition : Overnight on Oxygen
Diagnosis : COPD
Diagnosis2 :
Diagnosis3 :
Scheduled Date : 7/4/2012 6:26:01 PM
Upload Date: 7/25/2012 10:58:17 AM
Tech Edit Date: 10/14/2012 6:30:44 PM
Highest SpO2 : 98%
Average SPO2 : 89 %
Lowest SpO2 : 77%
Highest Pulse : 79 BPM
Average Pulse : 53 BPM
Lowest Pulse : 33 BPM
SpO2”03:38:12
SpO2 5% Protocol : 01:42:48
Group1 Qualifiers
11:29:23 PM
7:22:15 AM
SpO2”04:46:36
Group 1 Qualifier (5% Rule)
Group 2 Qualifiers
Group 1: Patient demonstrates saturation levels at or below 88% for five minutes or greater, taken during sleep, or a decrease in arterial oxygen saturation
greater than 5% for at least five minutes, taken during sleep, with associated symptoms. Contact your local Medicare Contractor for more specifics on these
diagnosis codes that support medical necessity.
Respiratory Assist Device (RAD): Sleep Oximetry demonstrates oxygen saturation ” for five minutes cumulative of nocturnal recording time (minimum
recording time of two hours) while breathing oxygen at 2 LPM or current prescribed FIO2, whichever is greater. If the patient meets Group 1 Qualifier and
satisfies the above test condition, this patient is a potential candidate. Check Local Guidelines
Longest Continuous Recording : 00:35:56
Number of Continuous Events > 5 Minutes : 9
Oxygen Destauration Index(ODI) : A desaturation event occurs when there is a 4% points or greater drop in oxygen saturation, within a three minute window
of onset. The Oxygen Desaturation Index (ODI) is calculated by the total number of desaturation events and dividing them by the valid time.
Events Per Hour (ODI) : 4.45
Total Desaturations (Entire Test): 35
Excluded Artifacts : 145
Patients with an ODI of 5 or more per hour should be evaluated for sleep apnea if your clinical judgment points in that direction. Two options are
an In-Lab Facility or Home Sleep Testing through Advanced Diagnostic Solutions.
Independent Diagnostic Testing Facility (IDTF)
Page 1 of 5
Advanced Diagnostics Solutions, Inc.
15283 Rester Dr, Brooksville, FL 34613
Phone: (352) 239-2810 | Web: www.DynamicDiagnostic.com
Patient : Jane Sampleton
Date of Birth : 12/25/1905
Physician Name : John Pepper
Test Condition : Overnight on Oxygen
Start Time : 7/24/2012 11:29:23 PM
End Time : 7/25/2012 7:22:15 AM
Nocturnal Pulse Oximetry: SPO2 and Heart Rate Graphs Page
Independent Diagnostic Testing Facility (IDTF)
Page 2 of 5
Advanced Diagnostics Solutions, Inc.
15283 Rester Dr, Brooksville, FL 34613
Phone: (352) 239-2810 | Web: www.DynamicDiagnostic.com
Patient : Jane Sampleton
Test Condition : Overnight on Oxygen
Date of Birth : 12/25/1905
Physician Name : John Pepper
Start Time : 7/24/2012 11:29:23 PM
End Time : 7/25/2012 7:22:15 AM
Nocturnal Pulse Oximetry: Destauration Events Page
Destaturation Event : This type of event is defined when a patient’s arterial oxygen saturation drops four percentage points
or more within a three minute window of onset. This type of event ends when the arterial oxygen saturation moves up one
percentage point or more and when there is missing, artifact or invalid data that is encountered during the desaturation
event. The top 35 Desaturation Events are listed below.
D
E
S
A
T
Excluded Artifacts : 145
Total Destaurations (Entire Test) : 35
Events Per Hour : 4.45
ID
Start Time
End Time
Duration
SPO2 Onset
SPO2 Low
Pulse Low
Pulse High
1
11:29:23 PM
11:30:28 PM
1:05
92
81
62
64
2
11:39:45 PM
11:42:03 PM
2:18
93
89
55
61
3
11:42:20 PM
11:43:43 PM
1:23
90
85
57
60
4
11:47:31 PM
11:49:15 PM
1:44
87
81
61
63
5
11:50:07 PM
11:51:50 PM
1:43
85
77
62
63
6
11:57:53 PM
11:58:45 PM
0:52
82
77
59
65
7
12:03:04 AM
12:03:15 AM
0:11
85
81
55
62
8
12:05:40 AM
12:06:39 AM
0:59
86
82
56
61
9
12:08:15 AM
12:09:38 AM
1:23
84
80
56
59
10
12:28:59 AM
12:30:47 AM
1:48
91
87
49
51
11
12:41:57 AM
12:42:35 AM
0:38
90
85
50
51
12
1:02:41 AM
1:03:23 AM
0:42
94
90
53
54
13
1:05:17 AM
1:05:27 AM
0:10
97
90
57
58
14
1:07:52 AM
1:09:08 AM
1:16
93
89
50
52
15
1:15:39 AM
1:16:10 AM
0:31
95
89
50
56
16
1:18:14 AM
1:18:56 AM
0:42
94
89
50
55
17
1:33:47 AM
1:34:08 AM
0:21
92
88
58
58
18
1:41:34 AM
1:43:04 AM
1:30
90
83
55
60
19
1:54:32 AM
1:54:42 AM
0:10
91
86
50
53
20
2:02:18 AM
2:02:42 AM
0:24
93
89
53
56
21
2:17:51 AM
2:19:49 AM
1:58
96
91
50
52
22
2:36:00 AM
2:38:29 AM
2:29
91
86
58
71
23
2:38:35 AM
2:40:12 AM
1:37
91
87
56
64
24
2:41:11 AM
2:41:18 AM
0:07
90
86
59
59
25
2:46:22 AM
2:46:36 AM
0:14
92
86
50
54
26
2:51:33 AM
2:52:59 AM
1:26
90
86
51
51
27
3:07:06 AM
3:07:34 AM
0:28
92
88
50
52
28
3:12:17 AM
3:14:46 AM
2:29
91
82
43
51
29
3:14:53 AM
3:15:13 AM
0:20
86
78
51
51
30
4:17:05 AM
4:18:25 AM
1:20
92
83
52
58
Independent Diagnostic Testing Facility (IDTF)
Page 3 of 5
Advanced Diagnostics Solutions, Inc.
15283 Rester Dr, Brooksville, FL 34613
Phone: (352) 239-2810 | Web: www.DynamicDiagnostic.com
Date of Birth : 12/25/1905
Patient : Jane Sampleton
Test Condition : Overnight on Oxygen
Start Time : 7/24/2012 11:29:23 PM
31
5:11:31 AM
5:13:46 AM
2:15
92
Physician Name : John Pepper
End Time : 7/25/2012 7:22:15 AM
87
53
60
32
5:21:53 AM
5:23:51 AM
1:58
91
87
53
56
33
5:24:29 AM
5:25:07 AM
0:38
88
84
55
59
34
5:29:40 AM
5:29:47 AM
0:07
96
91
47
61
35
5:58:11 AM
5:59:27 AM
1:16
92
88
60
67
Independent Diagnostic Testing Facility (IDTF)
Page 4 of 5
Advanced Diagnostics Solutions, Inc.
15283 Rester Dr, Brooksville, FL 34613
Phone: (352) 239-2810 | Web: www.DynamicDiagnostic.com
Patient : Jane Sampleton
Date of Birth : 12/25/1905
Physician Name : John Pepper
Test Condition : Overnight on Oxygen
Start Time : 7/24/2012 11:29:23 PM
End Time : 7/25/2012 7:22:15 AM
Pulse Oximetry Test: SpO2 & Pulse Breakdown
Percentage of Time Spent Page : This page will show a breakdown of the Pulse Oximetry Test at the individual SpO2
percentages from 99% - 40%.
SPO2 : 90
9.77 % time
SPO2 : 80
0.79 % time
SPO2 : 70
0.0 % time
SPO2 : 91
7.7 % time
SPO2 : 81
1.37 % time
SPO2 : 71
0.0 % time
SPO2 : 92
6.81 % time
SPO2 : 82
2.12 % time
SPO2 : 72
0.0 % time
SPO2 : 93
8.1 % time
SPO2 : 83
1.73 % time
SPO2 : 73
0.0 % time
SPO2 : 94
3.28 % time
SPO2 : 84
3.38 % time
SPO2 : 74
0.0 % time
SPO2 : 95
1.58 % time
SPO2 : 85
5.41 % time
SPO2 : 75
0.0 % time
SPO2 : 96
0.46 % time
SPO2 : 86
6.17 % time
SPO2 : 76
0.0 % time
SPO2 : 97
0.26 % time
SPO2 : 87
7.4 % time
SPO2 : 77
0.5 % time
SPO2 : 98
0.16 % time
SPO2 : 88
16.39 % time
SPO2 : 78
0.94 % time
SPO2 : 99
0.0 % time
SPO2 : 89
14.77 % time
SPO2 : 79
0.91 % time
Total 90'S
38.12 % time
Total 80'S
59.53 % time
Total 70'S
2.35 % time
SPO2 : 60
0.0 % time
SPO2 : 50
0.0 % time
SPO2 : 40
0.0 % time
SPO2 : 61
0.0 % time
SPO2 : 51
0.0 % time
SPO2 : 41
0.0 % time
SPO2 : 62
0.0 % time
SPO2 : 52
0.0 % time
SPO2 : 42
0.0 % time
SPO2 : 63
0.0 % time
SPO2 : 53
0.0 % time
SPO2 : 43
0.0 % time
SPO2 : 64
0.0 % time
SPO2 : 54
0.0 % time
SPO2 : 44
0.0 % time
SPO2 : 65
0.0 % time
SPO2 : 55
0.0 % time
SPO2 : 45
0.0 % time
SPO2 : 66
0.0 % time
SPO2 : 56
0.0 % time
SPO2 : 46
0.0 % time
SPO2 : 67
0.0 % time
SPO2 : 57
0.0 % time
SPO2 : 47
0.0 % time
SPO2 : 68
0.0 % time
SPO2 : 58
0.0 % time
SPO2 : 48
0.0 % time
SPO2 : 69
0.0 % time
SPO2 : 59
0.0 % time
SPO2 : 49
0.0 % time
Total 60'S
0 % time
Total 50'S
0 % time
Total 40'S
0 % time
SpO2 Time Breakdown
SpO2 Time <90% :
04:46:36
6S27LPH•
02:56:36
SpO2 Time <80% :
00:10:52
6S27LPH•
04:35:44
SpO2 Time <70% :
00:00:00
6S27LPH•
00:10:52
SpO2 Time <60% :
00:00:00
6S27LPH•
00:00:00
Pulse Percentage Breakdown
Pulse Range > 199
0.00 %
Pulse Range 90 - 99
0.00 %
Pulse Range 180 - 199
0.00 %
Pulse Range 80 - 89
0.00 %
Pulse Range 160 - 179
0.00 %
Pulse Range 70 - 79
0.27 %
Pulse Range 140 - 159
0.00 %
Pulse Range 60 - 69
10.52 %
Pulse Range 120 - 139
0.00 %
Pulse Range 50 - 59
86.04 %
Pulse Range 100 - 119
0.00 %
Pulse Range < 50
Independent Diagnostic Testing Facility (IDTF)
3.17 %
Page 5 of 5