Chronic Obstructive Pulmonary Disease (COPD)

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Chronic Obstructive Pulmonary Disease (COPD)

Progression

  • When did disease process start
  • Initial versus subsequent visit

Location

  • N/A

Acuity

  • Acute, chronic, or if with an acute exacerbation or acute respiratory failure (specify if hypoxic or hypercapnic)

Name

  • COPD includes chronic obstructive bronchitis, chronic bronchitis with airway obstruction, chronic bronchitis with emphysema, and chronic obstructive tracheobronchitis

Necessary Procedures

  • Interventions used to stabilize patient-nebulizers, inhalers, bronchodilators, intubation with mechanical ventilation, etc.

Other

  • If patient is on continuous home oxygen and patient has chronic respiratory failure
  • Any significant findings on chest x-rays-infiltrates, atelectasis, effusions, pneumothorax, fibrosis, etc.

Why

  • If patient has an acute lower respiratory tract infection and specify the infectious agent
  • All comorbid conditions, underdosing of medications, etc.
  • All related tobacco use, abuse, dependence, past history, or exposure (second hand, occupational)