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FLOW SHEET COPD Care Provider

Patient

Clinic:

Millway Medical Centre Inc.

Name :

Patient Test

Title:

Dr.

D.O.B :

March 8, 1988

Physician:

Zuchelkowski, Jan

Sex :

Female

Phone#:

905-607-0017

Address :

Mississauga ON

Fax#:

905-607-0078

Primary Phone :

--

Diagnosis Assessment Date

Description

Onset Date

No Data To Display

MEDICAL HISTORY

Allergy

Medications No Data To Display

Injection

No Data To Display

Family History No Data To Display

Social History Category

No Data To Display

Immunization Comment

No Data To Display

Tobacco

User Defined

Problem List No Data To Display

Name

Result No Data To Display

Date


Provider

Patient

Clinic:

Millway Medical Centre Inc.

Name :

Patient Test

Title:

Dr.

D.O.B :

March 8, 1988

Physician:

Zuchelkowski, Jan

Sex :

Female

Phone#:

905-607-0017

Address :

Mississauga ON

Fax#:

905-607-0078

Primary Phone :

--

VISITATION Procedure

Target

Spirometry Performed Spirometry Results % COPD Classification Oxygen Saturation % Recommend Arterial Blood Gas Smoking Status (Yes/No) Smoking Cessation Discussed Smoking Cessation Program Referred BMI Reviewed Need for Supplemental Oxygen (1 Year) Review need for nocturnal ventilated support (1 Year) Specialist Referral Review Pathophysiology, Prognosis, Treatment (6 Month) Patient Sets Physical Activity Goal (6 Month) Physical Activity Goal Reviewed Medication Use & Side Effects (6 Month) Provide Patient Education Materials Pulmonary Rehabilitation Referral Exacerbation Plan in Place/Reviewed (6 Month) Date of Last Exacerbation Influenza Vaccine Date (1 Year) Pneumococcal Vaccine Date

0-27

Patient Target

Base Line

24-April-2012


Signature : Footer


Copd flowsheet