COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)
FLOW SHEET/ ENCOUNTER FORM
! PATIENT NAME
CO-MORBID CONDITIONS AND OTHER FACTORS
ANXIETY
DEPRESSION
ATRIAL FIBRILLATION
ISCHEMIC HEART DISEASE
CACHEXIA AND MALNUTRITION
OSTEOPOROSIS
CANCER
OTHER RHYTHM PROBLEMS
CATARACTS
HYPERTENSION
CONGESTIVE HEART FAILURE
METABOLIC DISORDERS
GLAUCOMA
SKELETAL MUSCLE DYSFUNCTION
DIAGNOSTIC/ CLINICAL DATA, BY DATE
REVIEW
! HEALTH # (OR OTHER UNIQUE PATIENT ID)
! PHONE (INCLUDE AREA CODE)
CHART NUMBER
DIAGNOSIS
! BIRTHDATE (DD-MMM-YYYY)
CITY
POSTAL CODE
! PROVIDER NAME
! REASON FOR TODAY’S VISIT
PROVIDER ID #
" = RECALL
NEW DATA
DATE OF VISIT:
SCHEDULED
URGENT
DATE ! SPIROMETRY - FEV1/FVC post-bronchodilator
< 0.7 confirms COPD
FEV1
FEV1 ( MRC DYSPNEA SCALE
ENTER VALUE (1-5):
YES
! WRITTEN ACTION PLAN
EXACERBATIONS
Undifferentiated
Female
Male
MOST RECENT DATA
! = MANDATORY FIELDS
! GENDER
NO
) % PREDICTED
DEVELOPED/REVIEWED
! # OF EXACERBATION(s) IN LAST YEAR AND DATE
OF LAST (partial date allowed e.g. 2008, 2008/01)
# DATE OF LAST: MEDICATIONS SINCE LAST VISIT
ANTIBIOTICS
PREDNISONE
! COPD URGENT CARE SINCE LAST VISIT
#ER VISITS:
#HOSPITAL ADMISSIONS:
#WALK INS:
YES
YES
2nd Hand
NEVER
CURRENT
PAST
CURRENT SMOKER
EX-SMOKER QUIT DATE (partial date allowed e.g.
2008, 2008/01)
NO
NO
DATE
LIFESTYLE
COUNSELLING TO STOP
PHARMACOLOGIC INTERVENTION
! IF CURRENT SMOKER, WAS CESSATION
OFFERED? (check all that apply)
PROGRAM REFERRAL
PD
PHYSICAL ACTIVITY GOALS
DEVELOPED/REVIEWED
VACCINES
TARGET BODY MASS INDEX (BMI) Target 19 – 25
Height:
Enter weight (LBS or KG)
LBS
COMPLETED
DATE
COMPLETED
DATE
! ANNUAL INFLUENZA VACCINE
PNEUMOCOCCAL VACCINE
THERAPY
TNS
KG
CI
PD
CI
PD
SABD (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:
! CURRENT MEDICATION (check all that apply)
INHALER/SPACER TECHNIQUE REVIEWED?
YES
O2 SATURATION COMPLETED
REFERRALS
NO
SaO2:
NO
%
BLOOD GASES
YES
OXYGEN THERAPY
CONTINUOUS
NOCTURNAL
! PULMONARY REHABILITATION REFERRAL?
YES
OTHER REFERRALS (check all that apply)
PaO2:
mmHg
PaCO2:
mmHg
EXERCISE
EXER. AND NOCT.
NONE
NO
NO
NP
COPD PROGRAM
NP
RESP. SPECIALIST
NP
CERT. RESP. EDUCATOR
NP
SAIL O2 TESTER
NP
DIETITIAN
NP
OTHER REFERRALS: END OF LIFE ISSUES DISCUSSED
CI – contraindicated
Adapted from BCMA Flowsheet – May 25, 2009
YES
PD – patient declined
NP – no program available
NO
PD
TNS – tried or not suitable
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COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)
FLOW SHEET/ ENCOUNTER FORM
! PATIENT NAME
! HEALTH # (OR OTHER UNIQUE PATIENT ID)
! GENDER
Male
! PHONE (INCLUDE AREA CODE)
CHART NUMBER
CITY
! PROVIDER NAME
Undifferentiated
Female
! BIRTHDATE (DD-MMM-YYYY)
POSTAL CODE
PROVIDER ID #
COMMENTS
Date:
Date:
Date:
Adapted from BCMA Flowsheet – May 25, 2009
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