COPD Patient Evaluation Patient Name DOB MRN

Date Chief Complaint or Reason For Visit

Time
ROS WNL See HPI HPI Symptom Severity and Frequency
Constitutional ‰ ‰ ‰Asymptomatic with usual activity FEV1 FEV1
Eyes ‰ ‰  ‰Symptomatic with usual activity
FVC
 ‰Symptomatic with minimal activity
ENT/mouth ‰ ‰ 
‰At risk >80% t 70%
Resp ‰ ‰ 
‰Symptomatic at rest ‰Mild >79% <70%
CV ‰ ‰  ‰Recent antibiotic use ‰Moderate 50-79% < 70%
GI ‰ ‰  ‰Recent oral steroid use
GU ‰ ‰  ‰Recent ED visits ‰Severe 30-49% < 70%
Musc ‰ ‰ ‰Recent hospital admissions ‰Very <30% < 70%
Skin/breasts ‰ ‰ ‰Weight loss/Decreased appetite Severe

Neuro ‰ ‰ Physical Exam ‰Checkedwww.e-medtools.com

box indicates findings are within normal limits
General ‰ Alert Vital signs Temp Pulse BP RR Pulse ox at rest
Endo ‰ ‰ With exercise
Heme/lymph ‰ ‰ ENT ‰ Nasal mucosa ‰ Dentition ‰ Oropharynx Mallampati ‰I ‰II ‰III ‰IV
Allergy/Immun ‰ ‰ Neck ‰ Palpation ‰www.e-medtools.com
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
PMSH ‰ ‰ Lymph ‰ Lymph nodes Tobacco Use
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Social ‰ ‰ Musc ‰Tone ‰ Gait ______ # Packs X ______ # Yrs

Family ‰ ‰ Extrem ‰ Digits ‰Never smoked
COPD Therapy Skin ‰ No rashes, ecchymoses, nodules, ulcers ‰Quit
Current New ‰Unwilling to quit
‰Willing to consider quitting
Short-acting beta ‰ ‰ Neuro ‰ Orientation www.e-medtools.com
‰Affect ‰Quit, but resumed smoking
agonist
‰Willing to quit within 1 month
Inhaled steroid ‰ ‰ Impression and Plan Tests to be ordered
Long-acting beta ‰ ‰ ‰Bronchoscopy
agonist ‰Pulmonary Function Testing
Long acting anti- ‰ ‰ www.e-medtools.com ‰Methacholine challenge
cholinergic ‰6 Minute Walk Test
‰Sleep study
Theophylline ‰ ‰ ‰CXR
Oral steroids ‰ ‰ ‰Chest CT ‰without contrast
Antibiotics ‰ ‰ www.e-medtools.com ‰Echocardiogram with
‰Bubble study ‰PA pressures
Nicotine ‰ ‰ ‰Cardiopulmonary Stress Test
replacement
‰Pulmonary Rehabilitation
Buproprion ‰ ‰ ‰Surgical eval for lung reduction
Nicotine receptor ‰ ‰ ‰Bone density evaluation
blocker ‰Pneumococcal vaccine
CPAP ‰ ‰ ‰Influenza vaccine
‰Labs

Education and Instruction

BiPap ‰ ‰
Oxygen Therapy ‰Smoking cessation
Follow up ‰Peak flow meter use
‰Inhaler use
‰Importance of vaccinations
‰Risks of alcohol, narcotics and BZD
Signature ‰Medication side effects
CODE STATUS: ‰ Full code ‰ Do Not Attempt Resuscitation ‰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