COPD Flowsheet - Chronic Disease Network & Access Program

COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)FLOW SHEET/ ENCOUNTER FORMCO-MORBID CONDITIONS AND OTHER FACTORSANXIETYATRIAL FIBRILLATIONCACHEXIA AND MALNUTRITIONCANCERCATARACTSCONGESTIVE HEART FAILUREGLAUCOMADEPRESSIONISCHEMIC HEART DISEASEOSTEOPOROSISOTHER RHYTHM PROBLEMSHYPERTENSIONMETABOLIC DISORDERS PATIENT NAME HEALTH # (OR OTHER UNIQUE PATIENT ID) GENDER UndifferentiatedMale Female PHONE (INCLUDE AREA CODE) BIRTHDATE (DD-MMM-YYYY)CHART NUMBER CITY POSTAL CODESKELETAL MUSCLE DYSFUNCTION PROVIDER NAME PROVIDER ID #DIAGNOSTIC/ CLINICAL DATA, BY DATEREVIEW = MANDATORY FIELDSMOST RECENT DATANEW DATADATE OF VISIT: REASON FOR TODAY’S VISIT SCHEDULED URGENT = RECALLDIAGNOSIS SPIROMETRY - FEV1/FVC post-bronchodilatorYES NO DATE < 0.7 confirms COPDFEV 1FEV 1 ( ) % PREDICTEDMRC DYSPNEA SCALE ENTER VALUE (1-5):EXACERBATIONS WRITTEN ACTION PLAN # OF EXACERBATION(s) IN LAST YEAR AND DATEOF LAST (partial date allowed e.g. 2008, 2008/01)MEDICATIONS SINCE LAST VISIT COPD URGENT CARE SINCE LAST VISITCURRENT SMOKEREX-SMOKER QUIT DATE (partial date allowed e.g.2008, 2008/01)DEVELOPED/REVIEWED# DATE OF LAST: ANTIBIOTICSPREDNISONE#ER VISITS:#HOSPITAL ADMISSIONS:#WALK INS:CURRENTPASTDATEYESYESCOUNSELLING TO STOP2 nd HandNEVERNONOLIFESTYLE IF CURRENT SMOKER, WAS CESSATIONOFFERED? (check all that apply)PHARMACOLOGIC INTERVENTIONPROGRAM REFERRALPDPHYSICAL ACTIVITY GOALS DEVELOPED/REVIEWED NO TNSVACCINESTARGET BODY MASS INDEX (BMI) Target 19 – 25Height: Enter weight (LBS or KG) ANNUAL INFLUENZA VACCINEPNEUMOCOCCAL VACCINE CURRENT MEDICATION (check all that apply)LBSCOMPLETED CI PDDATECOMPLETED CI PDDATEKGSABD (e.g. Atrovent, Bricanyl, Ventolin)LAAC (e.g. Spiriva)LABA (e.g. Oxeze, Serevent)ICS/LABA (e.g. Advair, Symbicort)THEOPHYLLINE (e.g. Uniphyll)OTHER MEDS:THERAPYINHALER/SPACER TECHNIQUE REVIEWED? YES NOO 2 SATURATION COMPLETEDBLOOD GASESOXYGEN THERAPYSaO 2 : %YESNOCONTINUOUSNOCTURNAL PULMONARY REHABILITATION REFERRAL? YES NO NPPaO 2 : mmHgPaCO 2 : mmHgEXERCISEEXER. AND NOCT.NONECOPD PROGRAMNPREFERRALSOTHER REFERRALS (check all that apply)RESP. SPECIALISTCERT. RESP. EDUCATORSAIL O 2 TESTERNPNPNPDIETITIANNPOTHER REFERRALS: END OF LIFE ISSUES DISCUSSED YES NO PDCI – contraindicated PD – patient declined NP – no program available TNS – tried or not suitableAdapted from BCMA Flowsheet – May 25, 2009 Page 1 of 2

COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)FLOW SHEET/ ENCOUNTER FORM PATIENT NAME HEALTH # (OR OTHER UNIQUE PATIENT ID) GENDER UndifferentiatedMale Female PHONE (INCLUDE AREA CODE) BIRTHDATE (DD-MMM-YYYY)CHART NUMBER CITY POSTAL CODE PROVIDER NAME PROVIDER ID #Date:COMMENTSDate:Date:Adapted from BCMA Flowsheet – May 25, 2009 Page 2 of 2