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:_______________________________