Chronic Obstructive Pulmonary Disease Evaluation
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COPD Evaluation Date
Patient
Time
Constitution Fatigue or Malaise Fever or chills
DOB
MRN
Chief complaint/Reason for consult
Yes
No
History of Present Illness
Referring MD
Patient is Nonverbal.
History obtained from
Family Medical records
Appetite changes Eyes Vision changes New eye pain
S m A ed M P to L ol E s. co m
ENT/mouth Nose bleed Dental caries
Recent Antibiotic use Recent ER visits Recent cent Weight loss lo los or decreased appetite Recent Oral steroid use Recent Hospital al admissions admis Planned ed air travel tra in near future Spirometry evaluation performed within thin in previous 12 months
Dental abscesses Jaw pain Respiratory Dyspnea Cough
COPD Symptoms Asymptomatic with usual activity ity ty
Phlegm Hemoptysis
Symptomatic with usual activity tivity Symptomatic with minimal mal al activity activ Symptomatic at rest
<70% < 70% 7 <70% <70 <70% 70%
Wheeze Cardiovascular Chest pain Diaphoresis
Palpitations
Mild Moderate Severe Very ry Severe S
Increased dy dys dyspnea Increased ncreased sputum production
Allerg Allergies
Asthma ma Inflammatory mmatory Bowel Disease Dise Chemotherapy Notes Adrenall dysfunction dysfunct Neuromuscular uromuscular cular weakness Colonoscopy Arthritis A RA RA Osteoporosis rosi ECHO/Stress test Blood clots DVT PE Organ transplant trans t Immunosuppressive therapy CHF Pancreatitis Mammogram COPD Per Peripheral ipheral Artery Disease Dise Dis Organ failure Coronary ronary Artery Disease Pituitary infarct oor hemorrhagePFTs Cystic Fibrosis Protein deficie deficiency C S Pap Smear Dia Diabetes 1 2 Renal nal dysfu dysfunction dy ESRD Prior intubations Endocarditis Hemodi Hemodialysis emod Peritoneal dialysis Radiation exposure GERD Sarc Sarcoidosis Sleep study Gout SSeizure disorder Steroid use, chronic Hemolytic lytic anemia Sleep Apnea CPAP BiPAP Hepatic patic dysfunction sfunction Systemic Lupus Erythematosis Tuberculosis HIV/AIDSS Thrombocytopenia ITP TTP PPD Result Positive Negative Date Hype Hypertension ertension Thyroid disease hypo hyper Tuberculosis Treatment
Weight changes Constipation or Diarrhea Abdominal pain Genitourinary Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Claudication symptoms Skin/Breasts Masses New skin lesions
Malignancy ignancy
Sensitivity to sun
Adrenal renal Colon on L Leukemia/Lymphoma Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular Stage ge Treat Treatment T Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx
Neurologic Headaches
Surg Surgeries CABG Splenectomy Organ transplant Social History / Risk factors So
e-
Seizures
Tremors
>79% 50-79% 50 30-49% <30%
Chronic Bronchitis symptoms sym Increased cough co
Past Medical, Family S Social History
Gastrointestinal Nausea or vomiting
Polydipsia
SEVERITY SEV SE At risk
Medications reviewed eviewed Aller Allergy List reviewed Medications reconciled nciled with Nursing Home or Hospital discharge Information tion 46 6 N No food or drug allergies
Syncope
Endocrinologic Hair loss
FEV1 >80% 0%
Medications
Ankle edema
Muscle weakness
FEV1/FVC 70% 0%
Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology
Lung resection Pleurodesis Other
Deni Denies Yes D D Denies Yes Denies Yes
Ever smoker ___ # Packs X ____ # Yrs Recreational drug use Denies Yes Inhalation Injection Ingestion Chews tobacco Drug dependence Denies Yes Narcotics Benzodiazepines Quit tobacco use Quit date _________ Alcohol use Denies Yes ___ Drinks per Day Week Willingness to Quit Unwilling Considering Quit but resumed Within 1 month Patient has tried smoking cessation aids Nicotine replacement Buproprion or nortriptyline Nicotine receptor blockade
Occupational and Exposure History Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic Military Experience Chemicals or fires
Sinus problems Recurrent infections
©MB and RR 2006-2009
Family Medical History
Asthma CHF COPD Coronary Artery Disease MalignancyPancreatitis Thrombotic disorder Revised 16Sep09
e-medtools.com
Health Care Provider Signature
COPD Evaluation
Patient
DOB
Exam To qualify as a comprehensive exam:
MRN
General Multisystem requires performing ALL of 9 organ systems, AND 2 elements documented in each organ system
Respiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND
Ventilator
Mode ACSIMV PC PRVC
Constitutional ( 3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam Height ___________
Rate
Tidal Vol
______
PEEP ______
Plateau
______
FiO2 ______
PO2/FiO2 ______
______
NonInvasive Ventilator
CPAP BiPAP IE ____ IV Medications
Antiarrhythmics Antihypertensives Diuretics Drotrecogin alfa Heparin Insulin Antibiotics Lines & Monitors
Telemetry Chest tube
Left Air leak
ENT
Neck
Narcotics Pressors Sedation Steroids Thrombolytic TPN
present absent
WNL NL Erythema or scarring consistent with h recent or old radiatio radiation dermatitis Nodules palpable lpable Neck mass _____________________ ____ _ present a, v or cannon a waves presen present Jugular ular Veins WNL JVD p ula Thyroid WNL Thyromegaly yrome
Resp
WNL L = Within Normal Limits
Chest hest is free of defects de defects, expands normally rmally and nd symmetrically Erythema consistent with radiation dermatitis Scarring carring consis consi consistent with old, healed radiation dermatitis Surgical scar present Scar, other WNL Accessory W ory muscle use Intercosta Intercostal erco retractions Paradoxic movements Resp effort WN ness tto o percussion Lt Rt Hyperresonance Lt Rt Chest percus percuss percussion WNL Dullness Tactile fremitus Ta fre WNL Increased rea Decreased De Decreas __________________________________ L Bronchial breath sounds sound Egophony Rales Rhonchi Wheezes Rub present soun Aus Auscu Auscultation WNL
CV
WNL = Within Normal Limits W mits
GI
WNL = Within Normal Limits
Clear S1 S2 No murmur, rub or ga gallop Gallop audible Rub audible Murmur ur present nt Systolic ystolic Diastolic Grade I II III IV V VI Peripheral eripheral al pulses palpable No peripheral edema Peripheral pulses Absent Weak
WNL Mass present LUQ RUQ LLQ RLQ ______________ Pulsatile Liver and spleen ppa palpation WNL Unable to palpate Liver Spleen Enlarged Liver Spleen Lymph nod node exam WNL
WNL = Within Normal Limits
Musc c
Neck Axilla Groin Other ___________________ Neck Axilla Groin Other ___________________
Areas examined
Lymphadenopathy noted in Lympha Lymp
WNL = Within With Normal Limits
M Muscle tone WNL, and no atrophy noted Tone is Increased Decreased Atrophy present Gait and station WNL Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
Extrem WNL = Within Normal Limits Ex
No sign of infection
____ / ____ / ____ / \ \ \
CXR CT/Chest Other
©MB and RR 2006-2009
WNL = Within Normal Limits imits
Neck
Site No sign of infection
Radiology
WNL Edema Edem or erythema presentt Ging Gingivitis Oropharynx WNL Edema or erythema pre pres present Oral ulcers cers Oral Petechiae II IV V Mallampati I II III
Lymph (2 2 areas must be examined) ex
No sign of infection
\____/ / \
WNL = Within Normal Limits
Abdomen n
Peripheral venous access
Labs
Body habitus wnl Cachectic Obese bese ese Grooming wnl Unkempt Nasal mucosa, septum, and turbinates rbinates
EE ____
Trach present Size Endotracheal tube Size NG/ND tube PEG/PEJ tube Foley catheter Ostomy Central line/PICC
Port access
kg
L D Dental caries Dentition and gums WNL
Right Air leak present absent
Site
Weight ___________ lb
e- S m A ed M P to L ol E s. co m
______
in cm
Temperature __________ Pulse Rate __________ AND Rhythm Regular egul Irregular Blood Pressure sitting _____ / _____ OR standing _____ / _____ OR lying _____ / _____ ng __ ___ Respiratory Rate__________ Optional onal nal Sa Sats _____ % Cardiac Output _____ SVR _ S _____
Intubation date ____ / ____ / ____ ETT size _____ PS
1 element in every other organ system is expected
Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt
Skin Sk
WNL = Within Normal Limits
Neuro
WNL = Within Normal Limits
No rashes, ecchymoses, nodules, ulcers Rash Bullae Pressure Ulcer Stage 1 2 3 4 Oriented NOT oriented to Person Time Place Affect is WNL OR Patient appears Agitated Anxious Depressed
Additional Findings
Revised 16Sep09
________________________
e-medtools.com
Glasgow Coma Score E _____ V _____ M _____
Health Care Provider Signature
APACHE II Score __________
COPD Evaluation
Patient
DOB
MRN
Recommendations
Impression
Aggressive pulmonary toilet DVT prophylaxis Stress ulcer prophylaxis Daily sedation vacation and
I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
neurologic assessment
(send tip for culture)
s. Their T HCPOA is This patient has advanced health care directives.
S m A ed M P to L ol E s. co m
Head of bed elevated > 30 Degrees Intense glycemic control 100-150 Central line change or removal
decision maker) understands their medical condition and the consequences of their Code Status decision. Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION, Cardiac or Pulmonary
Physical therapy Enteral/Parenteral feeds Supplemental IV Fluids Smoking cessation aids Pneumonia vaccine prior to discharge Influenza vaccine prior to discharge Antiviral Treatment Prophylaxis Oseltamivir Zanamivir
Amantadine
Ramantadine
Antibiotics
Diagnostics
Metabolic Panel Basic Complete
e-
CBC with differential PT, PTT, INR HIV Hepatitis panel BNP Cardiac Enzymes Nasal or nasopharyngeal swab Nasal wash or aspirate Cultures Sputum Blood Urine CSF Bacterial Fungal AFB PPD Testing Quantiferon for TB Urinary Antigen Histoplasma Legionella Serum mycoplasma 12-lead EKG Echocardiogram Chest x-ray PA and Lateral Decubitus CT of chest Other
©MB and RR 2006-2009
Signature cc
Revised 16Sep09
e-medtools.com
Health Care Provider Signature
Patient
Time
Constitution Fatigue or Malaise Fever or chills
DOB
MRN
Chief complaint/Reason for consult
Yes
No
History of Present Illness
Referring MD
Patient is Nonverbal.
History obtained from
Family Medical records
Appetite changes Eyes Vision changes New eye pain
S m A ed M P to L ol E s. co m
ENT/mouth Nose bleed Dental caries
Recent Antibiotic use Recent ER visits Recent cent Weight loss lo los or decreased appetite Recent Oral steroid use Recent Hospital al admissions admis Planned ed air travel tra in near future Spirometry evaluation performed within thin in previous 12 months
Dental abscesses Jaw pain Respiratory Dyspnea Cough
COPD Symptoms Asymptomatic with usual activity ity ty
Phlegm Hemoptysis
Symptomatic with usual activity tivity Symptomatic with minimal mal al activity activ Symptomatic at rest
<70% < 70% 7 <70% <70 <70% 70%
Wheeze Cardiovascular Chest pain Diaphoresis
Palpitations
Mild Moderate Severe Very ry Severe S
Increased dy dys dyspnea Increased ncreased sputum production
Allerg Allergies
Asthma ma Inflammatory mmatory Bowel Disease Dise Chemotherapy Notes Adrenall dysfunction dysfunct Neuromuscular uromuscular cular weakness Colonoscopy Arthritis A RA RA Osteoporosis rosi ECHO/Stress test Blood clots DVT PE Organ transplant trans t Immunosuppressive therapy CHF Pancreatitis Mammogram COPD Per Peripheral ipheral Artery Disease Dise Dis Organ failure Coronary ronary Artery Disease Pituitary infarct oor hemorrhagePFTs Cystic Fibrosis Protein deficie deficiency C S Pap Smear Dia Diabetes 1 2 Renal nal dysfu dysfunction dy ESRD Prior intubations Endocarditis Hemodi Hemodialysis emod Peritoneal dialysis Radiation exposure GERD Sarc Sarcoidosis Sleep study Gout SSeizure disorder Steroid use, chronic Hemolytic lytic anemia Sleep Apnea CPAP BiPAP Hepatic patic dysfunction sfunction Systemic Lupus Erythematosis Tuberculosis HIV/AIDSS Thrombocytopenia ITP TTP PPD Result Positive Negative Date Hype Hypertension ertension Thyroid disease hypo hyper Tuberculosis Treatment
Weight changes Constipation or Diarrhea Abdominal pain Genitourinary Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Claudication symptoms Skin/Breasts Masses New skin lesions
Malignancy ignancy
Sensitivity to sun
Adrenal renal Colon on L Leukemia/Lymphoma Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular Stage ge Treat Treatment T Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx
Neurologic Headaches
Surg Surgeries CABG Splenectomy Organ transplant Social History / Risk factors So
e-
Seizures
Tremors
>79% 50-79% 50 30-49% <30%
Chronic Bronchitis symptoms sym Increased cough co
Past Medical, Family S Social History
Gastrointestinal Nausea or vomiting
Polydipsia
SEVERITY SEV SE At risk
Medications reviewed eviewed Aller Allergy List reviewed Medications reconciled nciled with Nursing Home or Hospital discharge Information tion 46 6 N No food or drug allergies
Syncope
Endocrinologic Hair loss
FEV1 >80% 0%
Medications
Ankle edema
Muscle weakness
FEV1/FVC 70% 0%
Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology
Lung resection Pleurodesis Other
Deni Denies Yes D D Denies Yes Denies Yes
Ever smoker ___ # Packs X ____ # Yrs Recreational drug use Denies Yes Inhalation Injection Ingestion Chews tobacco Drug dependence Denies Yes Narcotics Benzodiazepines Quit tobacco use Quit date _________ Alcohol use Denies Yes ___ Drinks per Day Week Willingness to Quit Unwilling Considering Quit but resumed Within 1 month Patient has tried smoking cessation aids Nicotine replacement Buproprion or nortriptyline Nicotine receptor blockade
Occupational and Exposure History Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic Military Experience Chemicals or fires
Sinus problems Recurrent infections
©MB and RR 2006-2009
Family Medical History
Asthma CHF COPD Coronary Artery Disease MalignancyPancreatitis Thrombotic disorder Revised 16Sep09
e-medtools.com
Health Care Provider Signature
COPD Evaluation
Patient
DOB
Exam To qualify as a comprehensive exam:
MRN
General Multisystem requires performing ALL of 9 organ systems, AND 2 elements documented in each organ system
Respiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND
Ventilator
Mode ACSIMV PC PRVC
Constitutional ( 3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam Height ___________
Rate
Tidal Vol
______
PEEP ______
Plateau
______
FiO2 ______
PO2/FiO2 ______
______
NonInvasive Ventilator
CPAP BiPAP IE ____ IV Medications
Antiarrhythmics Antihypertensives Diuretics Drotrecogin alfa Heparin Insulin Antibiotics Lines & Monitors
Telemetry Chest tube
Left Air leak
ENT
Neck
Narcotics Pressors Sedation Steroids Thrombolytic TPN
present absent
WNL NL Erythema or scarring consistent with h recent or old radiatio radiation dermatitis Nodules palpable lpable Neck mass _____________________ ____ _ present a, v or cannon a waves presen present Jugular ular Veins WNL JVD p ula Thyroid WNL Thyromegaly yrome
Resp
WNL L = Within Normal Limits
Chest hest is free of defects de defects, expands normally rmally and nd symmetrically Erythema consistent with radiation dermatitis Scarring carring consis consi consistent with old, healed radiation dermatitis Surgical scar present Scar, other WNL Accessory W ory muscle use Intercosta Intercostal erco retractions Paradoxic movements Resp effort WN ness tto o percussion Lt Rt Hyperresonance Lt Rt Chest percus percuss percussion WNL Dullness Tactile fremitus Ta fre WNL Increased rea Decreased De Decreas __________________________________ L Bronchial breath sounds sound Egophony Rales Rhonchi Wheezes Rub present soun Aus Auscu Auscultation WNL
CV
WNL = Within Normal Limits W mits
GI
WNL = Within Normal Limits
Clear S1 S2 No murmur, rub or ga gallop Gallop audible Rub audible Murmur ur present nt Systolic ystolic Diastolic Grade I II III IV V VI Peripheral eripheral al pulses palpable No peripheral edema Peripheral pulses Absent Weak
WNL Mass present LUQ RUQ LLQ RLQ ______________ Pulsatile Liver and spleen ppa palpation WNL Unable to palpate Liver Spleen Enlarged Liver Spleen Lymph nod node exam WNL
WNL = Within Normal Limits
Musc c
Neck Axilla Groin Other ___________________ Neck Axilla Groin Other ___________________
Areas examined
Lymphadenopathy noted in Lympha Lymp
WNL = Within With Normal Limits
M Muscle tone WNL, and no atrophy noted Tone is Increased Decreased Atrophy present Gait and station WNL Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
Extrem WNL = Within Normal Limits Ex
No sign of infection
____ / ____ / ____ / \ \ \
CXR CT/Chest Other
©MB and RR 2006-2009
WNL = Within Normal Limits imits
Neck
Site No sign of infection
Radiology
WNL Edema Edem or erythema presentt Ging Gingivitis Oropharynx WNL Edema or erythema pre pres present Oral ulcers cers Oral Petechiae II IV V Mallampati I II III
Lymph (2 2 areas must be examined) ex
No sign of infection
\____/ / \
WNL = Within Normal Limits
Abdomen n
Peripheral venous access
Labs
Body habitus wnl Cachectic Obese bese ese Grooming wnl Unkempt Nasal mucosa, septum, and turbinates rbinates
EE ____
Trach present Size Endotracheal tube Size NG/ND tube PEG/PEJ tube Foley catheter Ostomy Central line/PICC
Port access
kg
L D Dental caries Dentition and gums WNL
Right Air leak present absent
Site
Weight ___________ lb
e- S m A ed M P to L ol E s. co m
______
in cm
Temperature __________ Pulse Rate __________ AND Rhythm Regular egul Irregular Blood Pressure sitting _____ / _____ OR standing _____ / _____ OR lying _____ / _____ ng __ ___ Respiratory Rate__________ Optional onal nal Sa Sats _____ % Cardiac Output _____ SVR _ S _____
Intubation date ____ / ____ / ____ ETT size _____ PS
1 element in every other organ system is expected
Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt
Skin Sk
WNL = Within Normal Limits
Neuro
WNL = Within Normal Limits
No rashes, ecchymoses, nodules, ulcers Rash Bullae Pressure Ulcer Stage 1 2 3 4 Oriented NOT oriented to Person Time Place Affect is WNL OR Patient appears Agitated Anxious Depressed
Additional Findings
Revised 16Sep09
________________________
e-medtools.com
Glasgow Coma Score E _____ V _____ M _____
Health Care Provider Signature
APACHE II Score __________
COPD Evaluation
Patient
DOB
MRN
Recommendations
Impression
Aggressive pulmonary toilet DVT prophylaxis Stress ulcer prophylaxis Daily sedation vacation and
I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
neurologic assessment
(send tip for culture)
s. Their T HCPOA is This patient has advanced health care directives.
S m A ed M P to L ol E s. co m
Head of bed elevated > 30 Degrees Intense glycemic control 100-150 Central line change or removal
decision maker) understands their medical condition and the consequences of their Code Status decision. Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION, Cardiac or Pulmonary
Physical therapy Enteral/Parenteral feeds Supplemental IV Fluids Smoking cessation aids Pneumonia vaccine prior to discharge Influenza vaccine prior to discharge Antiviral Treatment Prophylaxis Oseltamivir Zanamivir
Amantadine
Ramantadine
Antibiotics
Diagnostics
Metabolic Panel Basic Complete
e-
CBC with differential PT, PTT, INR HIV Hepatitis panel BNP Cardiac Enzymes Nasal or nasopharyngeal swab Nasal wash or aspirate Cultures Sputum Blood Urine CSF Bacterial Fungal AFB PPD Testing Quantiferon for TB Urinary Antigen Histoplasma Legionella Serum mycoplasma 12-lead EKG Echocardiogram Chest x-ray PA and Lateral Decubitus CT of chest Other
©MB and RR 2006-2009
Signature cc
Revised 16Sep09
e-medtools.com
Health Care Provider Signature
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