COPD Patient Care Flow Sheet
Patient Name (LAST, FIRST) Health Care # (i.e., BC PHN) Date of Initial Visit (DD/MM/YYYY)
Birth date (DD/MM/YYYY) Gender Phone Number (include Area Code) Height (cm)
Male Female
CO-MORBIDITIES ( alphabetized by row ) Annual Weight (kg)
Alcohol Overuse Asthma Arthritis Atrial Fib CHF
Cor pulmonale / PAH CVA Depression/Anxiety Diabetes GERD
Hypertension Hypoxemia Insomnia Ischemic Heart Disease Smoker Yes No
Kidney Disease Lipid Abnormality Liver Disease Obesity Ex-smoker since __________
Obstructive Sleep Apnea Osteoporosis PVD Rhinitis/Sinusitis
Bold = mandatory field = Yes / No / data / or date Baseline DATE OF VISIT (DD/MM/YYYY)
REVIEW EACH VISIT Date Date Date Date Date
DIAGNOSIS AND CLASSIFICATION
FEV1 % predicted
COPD Classification (see table 1 on reverse side)
PREVENTION
Date of annual flu vaccine?
Pneumococcal vaccine in past 5 years?
THERAPY
Has the patient stopped smoking?
Brief smoking interventions provided?
Referral to stop smoking program?
Short-acting beta2 agonist?
Anticholinergic?
Long-acting beta2 agonist?
ICS? (see table 3 on reverse side)
Theophylline?
S & S of chronic hypoxemia or obstructive sleep apnea?
Specialist Referral? (see table 4 on reverse side)
Call back / return visit in 3 or 6 months?
EDUCATION AND SELF-MANAGEMENT
Review pathophysiology, prognosis and treatment
Ask patient to set a physical activity goal/assess progress
Review medication use and side effects
Provide GPAC patient guide
Refer to Pulmonary Rehabilitation?(see table 2 on reverse)
EXACERBATIONS
Exacerbation Action Plan in place?
Date of last exacerbation?
Corticosteroids prescribed?
Version Date: November 22, 2006
Record the antibiotic name or class prescribed and
document rotation
Table 1. COPD Classification using Medical Research Dyspnea Scale (MRC) and/or Spirometry
COPD
MRC Spirometry Symptoms
Classification
Normal spirometry: FEV1 / FVC > = 0.7 and/or Asymptomatic smoker or ex-smoker or chronic
0-1 At risk
FEV1 > = 80% of predicted cough and sputum
SOB from COPD with strenuous exercise or when
2 Mild FEV1/FVC 1 exacerbation in the past 12 months.
Table 4.
When to consider specialist referral?
The diagnosis is uncertain.
There are signs and symptoms of hypoxemic or hypercarbic respiratory failure.
The patient has the inability to cope due to social circumstances, anxiety, knowledge or complex/high
care needs.
There are severe or recurrent exacerbations and treatment failure.
The patient has severe COPD and disability requiring more intensive interventions.
More intensive co-morbidity assessment and management is required.
Version Date: November 22, 2006
A young patient with limited smoking history.
Difficulty in assessing home oxygen or sleep disorders.
Version Date: November 22, 2006