COPD Follow Up
1
COPD Patient Evaluation Patient Name DOB MRN Date Time Chief Complaint or Reason For Visit ROS WNL See HPI Symptom Severity and Frequency Constitutional Eyes FEV1 FEV1 FVC ENT/mouth At risk >80% 70% Resp Asymptomatic with usual activity Symptomatic with usual activity Symptomatic with minimal activity Symptomatic at rest Mild >79% <70% CV GI Moderate 50-79% < 70% GU Severe 30-49% < 70% Musc Skin/breasts HPI Recent antibiotic use Recent oral steroid use Recent ED visits Recent hospital admissions Weight loss/Decreased appetite Very Severe <30% < 70% Physical Exam Checked box indicates findings are within normal limits Neuro Endo General Alert Vital signs Temp Pulse BP RR Pulse ox at rest With exercise Heme/lymph ENT Nasal mucosa Dentition Oropharynx Mallampati I II III IV Allergy/Immun Neck Palpation Thyroid No JVD Psych Resp Auscultation Percussion Respiratory effort Palpation Chest wall History No changes See HPI CV Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema Allergies GI No palpable masses No hepatosplenomegaly No hepatojugular reflux Tobacco Use PMSH Lymph Lymph nodes Social Musc Tone Gait Family Extrem Digits COPD Therapy Current New Skin No rashes, ecchymoses, nodules, ulcers Short-acting beta agonist Neuro Orientation Affect ______ # Packs X ______ # Yrs Never smoked Quit Unwilling to quit Willing to consider quitting Quit, but resumed smoking Willing to quit within 1 month Inhaled steroid Impression and Plan Tests to be ordered Long-acting beta agonist Long acting anti- cholinergic Theophylline Oral steroids Antibiotics Nicotine replacement Buproprion Nicotine receptor blocker Bronchoscopy Pulmonary Function Testing Methacholine challenge 6 Minute Walk Test Sleep study CXR Chest CT without contrast Echocardiogram with Bubble study PA pressures Cardiopulmonary Stress Test Pulmonary Rehabilitation Surgical eval for lung reduction Bone density evaluation Pneumococcal vaccine Influenza vaccine Labs CPAP BiPap Education and Instruction Oxygen Therapy Follow up Signature CODE STATUS: Full code Do Not Attempt Resuscitation Smoking cessation Peak flow meter use Inhaler use Importance of vaccinations Risks of alcohol, narcotics and BZD Medication side effects Supplemental oxygen for air travel Data Reviewed ER Notes Old Chart EMS Note ECG Nursing Notes & Vitals log Labs X Rays MRI US CT Care Coordinated With ER MD HCPOA Primary Care MD Case Management Social Worker Pharmacy ©MB and RR 2006, 2007 www.e-medtools.com www.e-medtools.com www.e-medtools.com www.e-medtools.com www.e-medtools.com www.e-medtools.com www.e-medtools.com
-
Upload
e-medtools -
Category
Documents
-
view
2.017 -
download
5
description
The chronic obstructive lung disease (COPD) follow up MedicalTemplate is suitable for any health care provider that manages patients with COPD. This one page template contains detailed checklists for the severity of COPD symptoms, current and planned COPD therapy, and other features helpful for a comprehensive COPD treatment plan.
Transcript of COPD Follow Up
COPD Patient Evaluation Patient Name DOB MRNDateTime
Chief Complaint or Reason For Visit
ROS WNL See HPI Symptom Severity and FrequencyConstitutional � � Eyes � �
FEV1 FEV1FVC
ENT/mouth � � �At risk >80% � 70%Resp � �
�Asymptomatic with usual activity�Symptomatic with usual activity�Symptomatic with minimal activity�Symptomatic at rest �Mild >79% <70%
CV � �GI � �
�Moderate 50-79% < 70%
GU � � �Severe 30-49% < 70%
Musc � �Skin/breasts � �
HPI
�������
�Recent antibiotic use�Recent oral steroid use�Recent ED visits�Recent hospital admissions �Weight loss/Decreased appetite
�Very Severe
<30% < 70%
Physical Exam�Checked box indicates findings are within normal limitsNeuro � �
Endo � �General � Alert Vital signs Temp Pulse BP RR Pulse ox at rest
With exercise
Heme/lymph � � ENT � Nasal mucosa � Dentition� Oropharynx Mallampati �I �II �III �IVAllergy/Immun � � Neck � Palpation � Thyroid � No JVDPsych � � Resp � Auscultation � Percussion �Respiratory effort �Palpation �Chest wall
History No changes See HPI CV � Clear S1 S2 � No murmur � No gallop �No rub � Peripheral pulses � No peripheral edemaAllergies � � GI �No palpable masses� No hepatosplenomegaly� No hepatojugular reflux�
Tobacco Use PMSH � � Lymph � Lymph nodes�
Social � � Musc �Tone � Gait�Family � � Extrem � Digits�COPD Therapy
Current NewSkin � No rashes, ecchymoses, nodules, ulcers�
Short-acting betaagonist
� � Neuro � Orientation �Affect
______ # Packs X ______ # Yrs��Never smoked��Quit�Unwilling to quit �Willing to consider quitting �Quit, but resumed smoking �Willing to quit within 1 month
Inhaled steroid � � Impression and Plan Tests to be orderedLong-acting betaagonist
� �
Long acting anti-cholinergic
� �
Theophylline � �Oral steroids � �Antibiotics � �Nicotinereplacement
� �
Buproprion � �Nicotine receptorblocker
� �
�Bronchoscopy�Pulmonary Function Testing�Methacholine challenge �6 Minute Walk Test��Sleep study��CXR�Chest CT �without contrast �Echocardiogram with���Bubble study �PA pressures�Cardiopulmonary Stress Test �Pulmonary Rehabilitation�Surgical eval for lung reduction�Bone density evaluation�Pneumococcal vaccine �Influenza vaccine �Labs
CPAP � �
BiPap � �Education and Instruction
Oxygen TherapyFollow up
SignatureCODE STATUS: � Full code � Do Not Attempt Resuscitation
�Smoking cessation �Peak flow meter use�Inhaler use �Importance of vaccinations�Risks of alcohol, narcotics and BZD�Medication side effects �Supplemental oxygen for air travel
Data Reviewed� ER Notes � Old Chart �EMS Note�ECG�Nursing Notes & Vitals log � Labs� X Rays �MRI �US �CT
Care Coordinated With �ER MD �HCPOA �Primary Care MD �Case Management �Social Worker �Pharmacy
©MB and RR 2006, 2007 www.e-medtools.com
www.e-medtools.com www.e-medtools.com www.e-medtools.com www.e-medtools.com www.e-medtools.com
www.e-medtools.com
