**{note}Fill out this COPD patient summary template completely before finalizing.{endnote}
**Patient Summary**
Age: {formtext: name=Age}
Gender: {formmenu: Male; Female; Other; name=Gender}
Complexity/Severity: {formmenu: Mild; Moderate; Severe; name=Severity}
Chronic Conditions: {formmenu: COPD; Heart Failure; OSA; Anxiety; Diabetes; Hypertension; Other; multiple=yes; name=Chronic Conditions}
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**Utilization Drivers**
**Medical:**
{formmenu: severity of COPD; frequency of inpatient/outpatient exacerbations; baseline dyspnea with low reserve; history of medication nonadherence or inhaler technique challenges; recurrent respiratory infections; comorbidities complicating care (heart failure, OSA, anxiety); limited access to timely outpatient pulmonology; multiple=yes; name=Medical Drivers}
**Social:**
{formmenu: limited health literacy regarding early COPD exacerbation symptoms; transportation barriers to outpatient care; environmental triggers (smoking exposure, housing conditions, air quality); fragmentation of care; limited social supports; multiple=yes; name=Social Drivers}
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**Preferred Contact**
{formmenu: Self; Caregiver; Other; name=Contact Person}
Method of Communication: {formmenu: Phone; Text; Email; Portal; name=Contact Method}
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**Code Status**
{formmenu: Full Code; DNR; DNI; Unknown; name=Code Status}
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**PSR Instructions**
{formmenu: Low threshold to send to RN triage; Escalate for moderate exacerbation; Notify APC if worsening symptoms; Other; name=PSR Instructions}
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**Common Chief Concerns**
{formmenu: worsening baseline dyspnea; increased cough; increased sputum production; change in sputum color; wheezing or chest tightness; fatigue or decreased activity tolerance; anxiety related to breathing; running out of home medications; multiple=yes; name=Chief Concerns}
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**Triage Instructions**
{formmenu: Assess for change from baseline dyspnea; Assess oxygen needs; Assess sputum characteristics; Review recent hospitalizations; Review steroid/antibiotic use; Review discharge instructions; Confirm inhaler/nebulizer access and adherence; Escalate promptly for moderate exacerbation; multiple=yes; name=Triage Instructions}
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**Focused HPI**
{formmenu: Onset and trajectory of symptoms vs baseline; Identify triggers (infection, smoke, missed meds, exertion); Review home treatments attempted and response; Assess oxygen use and pulse oximetry; Evaluate for red flag symptoms (severe dyspnea, confusion, cyanosis); multiple=yes; name=Focused HPI}
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**APC Instructions**
{formmenu: Early initiation or adjustment of rescue plan (steroids, antibiotics per protocol); Reinforce inhaler technique and action plan; Coordinate urgent outpatient follow-up or same/next-day visit; Inform pulmonology office; multiple=yes; name=APC Instructions}
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**Physician Instructions**
{formmenu: Review recurrent exacerbation pattern; Optimize chronic management; Consider advanced therapies; Coordinate with pulmonology; Address palliative symptom support; Address high-risk decision-making; multiple=yes; name=Physician Instructions}
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**After Hours Instructions**
{formmenu: Adjust as needed based on above; Escalate to on-call provider if worsening symptoms; Provide patient education for urgent symptoms; Other; name=After Hours Instructions}
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**Clinical Data**
Location of Data: {formmenu: Athena; Outside EMR; Other; name=Data Location}
Outpatient Pulmonologist: {formtext: name=Pulmonologist}
Current COPD Regimen: {formmenu: LAMA; LABA; ICS; Combination inhaler; Nebulizer; Oxygen; Other; multiple=yes; name=Current Regimen}
Outpatient Treatment Plan: {formmenu: Continue current regimen; Adjust inhaler therapy; Initiate steroids/antibiotics per protocol; Schedule pulmonology follow-up; Other; multiple=yes; name=Outpatient Plan}
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**Patient Education**
{formmenu: Call Accompany Health first for worsening breathing or medication issues; Review individualized COPD action plan regularly; Reinforce early symptom recognition; Emphasize prompt outreach; Focus on preventing ED visits through early intervention; Address modifiable triggers/risk factors; multiple=yes; name=Patient Education}
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**Last Updated By:** {formtext: name=Updated By; default=Pooja Mehta}
**On:** {formdate: YYYY-MM-DD; name=Update Date}
---