COPD Evaluation For Outpatients - Medical Documentation Template

COPD Evaluation Patient _____________________________________ DOB _____ / _____ / _____ MRN ___________________
Date Time Chief complaint/Reason for consult Referring MD

Yes No
Constitution
Fatigue or Malaise History of Present Illness Patient is Nonverbal. History obtained from Family or Friend Medical records
Fever or chills Recent Weight loss or decreased appetite
Appetite changes Recent Antibiotic use
Eyes Recent Oral steroid use
Vision changes Recent ER visits
New eye pain Recent Hospital admissions
ENT/mouth Planned air travel in near future
Nose bleed
Chronic Bronchitis symptoms
Dental caries
Increased cough
Dental abscesses Increased dyspnea
Jaw pain Increased sputum production
Respiratory www.e-medtools.com
Dyspnea COPD Symptoms FEV1/FVC FEV1 SEVERITY Spirometry evaluation performed within previous 12 months
Cough Asymptomatic with usual activity 70% >80% At risk
Phlegm Symptomatic with usual activity <70% >79% Mild
Hemoptysis Symptomatic with minimal activity < 70% 50-79% Moderate
Wheeze Symptomatic at rest www.e-medtools.com
<70% 30-49% Severe
Cardiovascular
<70% <30% Very Severe
Chest pain Allergies Allergy List reviewed No food or drug allergies
Medications Medications reviewed Medications reconciled with Nursing Home or Hospital discharge Information
Diaphoresis
Ankle edema Past Medical, Family Social History
Syncope
Anemia Hypersensitivity pneumonitis Thyroid disease hypo hyper
Palpitations
Asthma www.e-medtools.com
Hypertension PPD Result Positive Negative Date
Gastrointestinal Adrenal dysfunction Inflammatory Bowel Disease Tuberculosis Treatment
Nausea or vomiting Arthritis RA Myocardial Infarction
Weight changes Blood clots DVT PE Neuromuscular weakness
Constipation or Cerebral Artery Disease Osteoporosis
Diarrhea CHF Pancreatitis Steroid use, chronic
Abdominal pain Churg Strauss Peripheral Artery Disease Immunosuppressive therapy
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Genitourinary COPD Pituitary infarct or hemorrhage Chemotherapy
Hematuria Coronary Artery Disease Protein deficiency C S Radiation exposure
Dysuria Cystic Fibrosis Renal dysfunction ESRD
Urethral discharge Diabetes 1 2 Dialysis Hemo Peritoneal Organ failure or transplant
Musculoskeletal DIC Sarcoidosis
Myalgias Endocarditis Seizure disorder ECHO/Stress test
Arthralgias GERD www.e-medtools.com PFTs
Joint swelling Gout Sleep Apnea CPAP BiPAP Pap Smear
Recent trauma Hepatic dysfunction Systemic Lupus Erythematosis Mammogram
Skin/Breasts Histiocytosis Strokes Colonoscopy
Masses HIV/AIDS Thrombocytopenia ITP TTP Sleep study
Malignancy www.e-medtools.com
New skin lesions
Sensitivity to sun
Adrenal Colon Leukemia/Lymphoma Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular
Stage Treatment Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx
Neurologic
Headaches
Surgeries CABG Splenectomy Lung resection Pleurodesis Organ transplantOther
Seizures
Muscle weakness
Social History / Risk factors
Endocrinologic No Yes Ever smoker ___ # Packs X ____ # Yrs Recreational drug use
Hair loss No Yes Chews tobacco No Yes Usual route Inhalation Injection Ingestion
Polydipsia No Yes Quit tobacco use Quit date _________ Drug dependence
Tremors Patient is unwilling to quit No Yes Narcotics Benzodiazepines
Neck pain Patient willing to consider quitting Alcohol use
Heme/Lymph Patient quit, but resumed smoking No Yes ___ Drinks per Day Week
Bleeding gums Patient willing to quit within 1 month
Unusual bruising No Yes Patient has tried smoking cessation aids Nicotine replacement Buproprion or nortriptyline Nicotine receptor blockade
Swollen lymph nodes Occupational and Exposure History
Allergy/Immunology Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter
Sinus problems Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals
Recurrent infections
Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic
Aerosolized water Source Hot tub Whirlpool baths High Pressure washings Other
Psychologic
Pets or feathers
Mood changes
Chemicals or fires Military Experience
Agitation Family Medical History
Hallucinations Asthma CHF COPD Coronary Artery Disease MalignancyPancreatitis Thrombotic disorder
©MB and RR 2006-2010 Revised 31Dec09 e-medtools.com Health Care Provider Signature
Exam To qualify as a comprehensive exam: 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 1 element in every other organ system is expected
Constitutional (Must include 3 vitals) WNL = Within Normal Limits
Labs Height ___________ in cm Weight ___________ lb kg
\____/ ____ / ____ / ____ /
/ \ \ \ \ Temperature __________ Pulse Rate __________ AND Rhythm Regular Irregular
Blood Pressure sitting __________ / __________ OR standing __________ / __________
Blood Pressure lying __________ / __________
Respiratory Rate__________ Optional Sats _____ % Cardiac Output _____ SVR _____
Body habitus WNL
Cachectic Obese
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Grooming WNL Unkempt
ENT
WNL Edema or erythema present
Nasal mucosa, septum, and turbinates
Dentition and gums WNL Dental caries
Gingivitis
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Oropharynx WNL Edema or erythema present Oral ulcers Oral Petechiae
Pulmonary Function Tests
Mallampati I II III IV
Neck
Neck WNL Erythema or scarring consistent with recent or old radiation dermatitis
Thyroid WNL Thyromegaly Nodules palpable Neck mass _____________________
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Jugular Veins WNL JVD present a, v or cannon a waves present
Respiratory
Chest Free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis
Scarring consistent withOld, healed radiation dermatitis Prior surgery Trauma Other
Polysomnography Respiratory effort WNL Accessory muscle use Intercostal retractions Paradoxic movements
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Chest percussion WNL Dullness to percussion Lt Rt Hyperresonance Lt Rt
Tactile fremitus WNL Increased Decreased __________________________________
Auscultation WNL Bronchial breath sounds Egophony Rales Rhonchi Wheezes Rub present
Cardiovascular
Heart sounds Clear S1 S2 No murmur, rub or gallop Gallop audible Rub audible
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Murmur present Systolic Diastolic Grade I II III IV V VI
Peripheral pulses Palpable and symmetric Absent Weak
Radiology Peripheral edema Absent Present
CXR CT/Chest Other Gastrointestinal
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Abdomen WNL Mass present LUQ RUQ LLQ RLQ ______________ Pulsatile
Liver and spleen Palpable and WNL
Unable to palpate Liver Spleen Organomegaly Liver Spleen
Lymphatics (2 areas must be examined)
Lymph node exam WNL Areas examined Neck Axilla Groin Other ___________________
Lymphadenopathy noted Neck Submental Axillary Epitrochlear Inguinal Other ___________
Musculoskeletal
Muscle tone WNL, and no atrophy noted Increased Decreased Atrophy present
Gait and station WNL Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
Extremities
Exam WNL Clubbing Cyanosis Petechiae Synovitis Rt Lt ________________________
Skin
Exam WNL Rash Ecchymosis Nodules Ulcer
Neurologic
Orientation Oriented NOT oriented to Person Time Place
Affect WNL Agitated Anxious Depressed
Additional Findings
Plan Impression
COPD Therapy I have personally discussed Code Status with this patient and I believe that this patient understands their medical condition
PRN albuterol “rescue agent” 52 and the consequences of their Code Status decision.
Inhaled corticosteroids Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION, Cardiac or Pulmonary

Long-acting beta agonist 52
This patient has an advanced health care directive, and has named _______________________________ as their HCPOA.
Theophylline
Long-acting anti-cholinergic 52
If no history of glaucoma or urinary retention
Oral steroids
Antibiotics for exacerbations
Smoking cessation aids
Long term oxygen therapy
Patient advised to quit smoking www.e-medtools.com
Patient advised of risks of alcohol,
narcotic and benzodiazepine use
Medication Side Effects discussed
Schedule Patient For www.e-medtools.com
Bronchoscopy
Pulmonary Function Testing
Methacholine Challenge
6 Minute Walk Test
Bone density evaluation www.e-medtools.com
CXR
Chest CT with contrast
ECHO with bubble study
assess PA pressures
Cardiopulmonary Stress Test www.e-medtools.com
Sleep Study
CT Surgery eval for lung reduction
Pneumococcal vaccine
Influenza vaccine
Pulmonary Rehabilitation www.e-medtools.com

Labs
CBC
BMP
CMP www.e-medtools.com
LFTs
Hepatitis panel
HIV
Alpha 1 antitrypsin
Signature
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COPD Evaluation For Outpatients - Medical Documentation Template

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COPD Evaluation Patient ___________________________________ DOB _ / _ / _ MRN _________________

Date Time Chief complaint/Reason for consult Referring MD

Blood Pressure lying /

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