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
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