COPD PATIENT CARE FLOW SHEET

VISIT 1: SCREENING AND DIAGNOSIS

Patient Name: ______
Date of Birth: ______ /

Date: ______

/ Influenza Vaccination: Yes Date______
No  Declined Past reaction/allergy
CASE FINDING
History /  Current smoker
 Former smoker
 Second-hand exposure to tobacco smoke / Pack years ______
Exacerbation History /  Oral corticosteroid
 Hospitalization
 Antibiotic for RTI /  ER visit
 ICU
Date of last exacerbation:
Current Symptoms /  Wheeze
 Breathlessness
 Chest tightness
 Cough
 How far can you walk before becoming dyspneic? /  Sputum
 Leg Fatigue
 Frequent colds that last longer than others
 Chest pain
______
MRC Level /  Grade 1
 Grade 2
 Grade 3
 Grade 4
 Grade 5 / Only short of breath on strenuous exertion
SOB going up slight hill or hurrying on the level
Walks slower than people the same age due to SOB or
Have to stop for breath walking on level ground
Stop for breath after walking 100 yd (90 m) or a few minutes on level ground
Too SOB to leave the house or SOB on dressing
DIAGNOSIS
COPD Diagnosis Confirmed /  YES  NO / If yes, how was diagnosis confirmed:
 Clinical assessment
 Spirometry(post BD FEV1/FVC ratio of <70%)
 Pulmonary function testing
 Specialist/Consultant
Test for A1AT deficiency /  Yes  No / Indications:
COPD developed at young age
More rapid disease progression than expected
Family history of COPD
COMPLETE THE FOLLOWING SECTION IF DIAGNOSIS OF COPD CONFIRMED
Medication
Prescribed at this Visit / Long Acting Bronchodilators Spiriva
 Serevent
 Oxeze
 Onbrez
Dosage: / Combination (LABA/ICS)  Advair MDI
 Advair Diskus
 Symbicort Turbuhaler
 Zenhale / Quick Relievers (Rescue) Airomir HFA MDI
 Atrovent
 Bricanyl Turbuhaler
 Oxeze Turbuhaler
 Ventolin Diskus
 Ventolin HFA MDI / Other Medications (anti-inflammatory)
 Daxas
 Oxygen
Smoking cessation  Still smoking?
 Contemplative stage
 Preparation
Action stage /  Referral to smoking cessation program / Medication prescribed?  Champix
 Buproprion /  Nicotine replacementGum
Patch
Inhaler
Electronic cigarette
Written Action Plan Provided /  YES  NO
Education Provided at this Visit /  Chronic nature of disease
 Inhaler technique
 Medications
 Breathing exercises /  Regular Exercise
 Pulmonary Rehabilitation
 Smoking cessation If yes,

Pneumococcal
Vaccination /  Yes  No / Indication q 10 years, (every 5 years for MRC level of 5)
Patient Understanding / Of diagnosis:
 Poor  Satisfactory  Good / Of education/information provided at this visit:
 Poor  Satisfactory  Good
Referral(s) /  Certified Respiratory education program
 Social Worker
 Dietician /  Respirologist
 Other: ______
Follow-up / ______weeks / ______months ______plan

PLEASE USE COPD FLOW SHEET FOR POST-DIAGNOSIS FOLLOW-UP VISITS 2 AND 3