Referral Portal
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Klingensmith HealthCare Transition of Care

Phone: 1-800-272-3233

Fax: 724-763-2531

Physician Order
Patient Information:
Name:
Address:
Phone:
Diagnosis:
Physician Information:
Physician:
Physician phone:
Physician fax:
Clinical Values:
FEV1.0:		Date Performed:	
PaCO2		
Items Prescribed:
	COPD Disease Transition Program, RCP visit
initially, one week, one month, and at 6 months to 
include the following:
  • Home assessment and plan of care
    • Home Safety
    • Risk of falls
  • Education and training on COPD Management(Disease process, medication usage, diet nutrition, smoking cessation, etc...)
  • Clinical Assessment
    • Vital signs(Heart Rate, Respiratory Rate, Breath Sounds, Blood Pressure)
  • Pulse Oximetry at rest, exercise, nocturnally(if not on oxygen therapy)
  • Evaluation of Oxygen usage
    • ADL testing using the Clinical Dose Recorder or Pulse Oximeter
    • Titration of Oxygen during ADL's and at rest, keep SpO2>90%
    • Compliance reporting at day 7, 30 and 6 months
  • Motivational goal setting

Baseline PFT--FEV1.0

Physician Signature____________________

Date:_______________________________

 
 
 
 
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