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					          Centre universitaire de santé McGill                                       Chart #: __________________                     Initials: ____ ____ ____

          McGill University Health Centre
                                                                                                                                     D.O.B.: _________________
          EVALUATION OF COPD CLIENTELE
                                                                                     POSTAL CODE: __________________
Date of Selection (dd/mm/yy):
Event:
Site:    MGH 1             RVH 1                      MCI 1                          GENDER: __________________
Department:            Medical Unit 1           ER 1
COPD 1                                COPD / Asthma               1
Emphysema          1                  Suspected COPD              1
Chronic bronchitis 1                  N/A                         1


                                      Information to be collected at the moment of the "EVENT"
  CATEGORY           QUESTIONS                                                                         Description

                                                                  Previous   Acute / Unstable at                                                       Previous Acute / Unstable at
                                      Respiratory:                 Stable           event          Other                                                Stable         event

                                      Cor Pulmonale:                   1             1             Cardiac disease                                         1            1
                                      Asthma:                          1             1             Cancer                                                  1            1
                   Mark all the co-
 COMORBIDITY       morbidities        Sleep Apnea:                     1             1             Psychiatric Disease (Dementia, alzheimer & other)       1            1
                   mentioned          Hypercapnia:                     1             1                                                                     1            1
                                      Hypoxemia:                       1             1                                                                     1            1
                                      Bronchiectasis:                  1             1                                                                     1            1
                                                                       1             1             Peripheral Vascular D          1 Neuromuscular Disease                  1
                                                                       1             1             Alcohol / drug abuse           1 Severe Arthritis                       1
                   Oxygen: more       Date:       dd / mmm / yy                                                            Date:     dd / mmm / yy
                   stable value, do
                                      Yes         1               No         1       N/A           1                       Blood Gas Results:          pH: ______________
                   not use
OXYGEN AT          prescription       Rx: _________ L / min.;      ___________ Hrs/day                                     Date      dd/mm/yy          pCO2: ___________
HOME               during             continued             1     on exertion only                 1                       (more recent to discharge) PO2: ____________
                   admission. Blood
                                      at night only         1     prn                              1                       FiO2:     1                 RA:       1
                   gas: when
                   available.         O2 Saturation: _______ %
                   Use stable
                   values, not        Date:       dd/mmm/yy       during event       1                   within last year 1                            N/A       1

SPIROMETRY
                   exacerbation                   Actual liters       Liters pred    % PRED                                          observed liters                 absolute
                   (unless no other
                                      FEV1                        L                  %                                     FEV1                        L
                   available). From                                                                                                                        =
                   PFT take PRE.      FVC                         L                   %                                    FVC                         L
                   Use MRC
DYSPNEA
                   Scale**            MRC given:                                     MRC estimated:                                                    N/A       1
                                      Never Smoked          1     Ex-smoker          1                           Current Smoker 1                      N/A       1
SMOKING            Does the Patient Packs per day:_____ # years: _______                 Pack-Years History (# ppd x # of years): ___________
STATUS             Smoke?           Is patient interested to
                                    quit?
                                                              Yes      1             No            1                       N/A       1

                                      Independent                 1                                                                                  N/A      1
                                      Restricted                  1                                                                 **** Language restriction 1
                   Household
*** SOCIAL
                   composition,       Housebound                  1                                Patient limited in daily activities because of his COPD 1
(Information:
                   psychosocial,      Bed -or chair- bound        1                                            Candidate or staying in a CHSLD or similar 1
where available)
                   homeless, etc.



                   Has the patient    Yes                   1     When: ________________                                   No        1                 N/A       1
PULMONARY
                 taken a
REHABILITATION                                             Mont
                 pulmonary
                                                           Sinai 1                                 1                                 1
(Information:                         Where:                                         MCI                                   Other                       _____________
where available)
                 rehabilitation
                   program (ever)?    Is pt. interested in rehabilitation program? Yes             1                       No        1                 N/A       1

Comments:
                                                                      Chart #:   __________________         Initials:           ____ ____ ____


              Information to be collected from DHIS and verified at Chart Review (if available)
            History for COPD
            reasons
                             Ever in ICU         1             Ever intubated    1                          Ever on CPAP/BIPAP          1


            HOSPITALIZATION                (ALL Reasons)                         EMERGENCY ROOM - D/C to HOME           (ALL reasons)

            12 months Before Event                                               12 months Before Event
                                       12 months After Event                                                12 months After Event
            (include Event)                                                      (include Event)


            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________

            In    dd/mm/yy      MCI    In   dd/mm/yy            MCI                                   MCI                               MCI
                                                                                 In    dd/mm/yy             In    dd/mm/yy
            Out dd/mm/yy        RVH    Out dd/mm/yy             RVH                                   RVH                               RVH
                                MGH                             MGH              Dx: ____________     MGH   Dx: ________                MGH
            Dx: ____________           Dx:________


Comments:
          Centre universitaire de santé McGill                                  Chart #:   __________________     Initials:      ____ ____ ____
          McGill University Health Centre
                                                                                                                  D.O.B.:        ___________
          EVALUATION OF COPD CLIENTELE
                                                                                POSTAL CODE:                __________________

Date of Selection (dd/mm/yy):
 Event:
Site:     MGH 1         RVH 1                           MCI 1                   GENDER: __________________

Department:            Medical Unit 1             ER 1

COPD      1

Emphysema         1                   Suspected COPD                     1
Chronic Bronchitis 1                  N/A                                1


                                      Information to be collected at the moment of the "EVENT"
                                                                                    CONSULTATION DURING EVENT

                                      SERVICES:                                 Doctor / Institution               Date          N/A   1
                                      Respirologist                      1      __________________          __________________
                                      Palliative Care
                                      (for terminal lung disease)        1      __________________          __________________

                                      Other                              1      __________________          __________________

                                                                                __________________          __________________

                                                                                           AT DISCHARGE

                       Mark all the   REFERENCES:                               Doctor / Institution               Date          N/A   1
SERVICE                               Respirologist
                       References
                                      (Appointment / follow-up)          1      __________________          __________________

                                      SRSAD                              1      __________________          __________________ New 1             F/U 1

                                      CLSC                               1      __________________          __________________ New 1             F/U 1

                                      Pulmonary Rehab.                   1      __________________          __________________ Waiting List? 1

                                      Smoking Cessation                  1      __________________          __________________

                                      (Reference or information given)

                                      Other: _______________ 1                  __________________          __________________

                                      Is the Patient Followed by a Family Doctor?                      Yes: 1                 No: 1        N/A: 1


Comments (for example if patient refused reference)
          Centre universitaire de santé McGill                                           Chart #:       __________________                          Initials:          ____ ____ ____
          McGill University Health Centre

          EVALUATION OF COPD CLIENTELE


Date of Selection (dd/mm/yy):
 Event:
Site:    MGH 1RVH 1                                  MCI 1

Department:           Medical Unit 1            ER 1


                                      Information to be collected at the moment of the "EVENT"
                   CHRONIC (prolongued) BASIS:                                                                                                           before        during        after D/C

                   1 - METHYLXANTHINES (theophylline)                                                                       (Theodur,Uniphyl)               1             1              1

                   2 - SABA - SHORT-ACTING B2-AGONIST                                 (Ventolin, Bricanyl, Berotec, Pro-air, Maxair, Airomir)               1             1              1

                   3 - LABA - LONG-ACTING B2-AGONIST (formoterol, salmeterol)                                       (Serevent, Foradil, Oxeze)              1             1              1

                   4 - SHORT ACTING ANTICHOLINERGIC            (ipratropium)                                                         (Atrovent)             1             1              1

                   5 - LONG ACTING ANTICHOLINERGIC (tiotropium)                                                                       (Spiriva)             1             1              1

                   6 - COMBINATION SHORT ACTING ANTICHOLINERGIC + SABA ( 2 + 4 )                                       (Combivent, Duovent)                 1             1              1
  RESPIRATORY
   MEDICATION
                   7 - ICS-INHALED CORTICOSTERIOD               (Beclovent, Becloforte, Flovent, Pulmicort, Azmacort, Vanceril, Bronalide, Q-Var)           1             1              1

                   8 - COMBINATION ICS + LABA ( 3 + 7 )                                                                     (Advair, Symbicort)             1             1              1

                   9 - SYSTEMIC (oral) CORTICOSTEROID FOR OVER 1 MONTH                               (Prednisone, Deltasone, Prednisolone)                  1             1              1

                   10 - ANTAGONIST OF LEUCOTRIENE                                                                          (Singular, Accolate)             1             1              1

                                      For EXACERBATION
                   Include medication
                     for exacerbation
                     even during the
                                      ANTIBIOTIC                                                                                                                                             1
                        admission
                                      SYSTEMIC (oral) CORTICOSTEROID FOR LESS THAN 1 MONTH                                                           (Prednisone, Deltasone, Prednisolone)   1

COMMENTS:




DEFINITIONS:

COPD: FEV1 (% pred) less than 80%, FEV1/CVF(% pred) less than 70%, 40 years and older and smoker or ex smoker.
* ER CRITERIA - EI Database
                    1 COPD
MGH, MCI                                                          RVH             1 SOB                        1 Discharged at Home
                    Patients
                    1 Discharged at Home                                          1 50 yrs or older            1 COPD Hospitalization within the last 3 years
** MRC SCALE
1. I only get breathless with strenuous exercise.
2. I get short of breath when hurrying on the level or walking up a slight hill.
3. I walk slower than people my age on the level because of breathlessness, or I have to stop for breath when walking at my own pace on the level.
4. I stop to breath after walking about 100 yards or after a few minutes on the level.
5. I am too breathless to leave the house.

*** SOCIAL STATUS
1. Independent - fully ambulatory and living without assistance
2. Restricted - able to live on their own and get out on their home to do basic necessities, but severly limited in exercise ability.
3. Housebound - cannot get out of the house unassisted or get out of the house rarely; able to perform self-care but unable to do
  heavy chores such as housecleaning; cannot live alone; may be institutionalized
4. Bed -or chair- bound

**** LANGUAGE RESTRICTION
Not able to communicate in English or French.

				
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posted:9/15/2011
language:French
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