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Clinical Audit Questionnaire Template

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Clinical Audit Questionnaire
Chronic Obstructive Pulmonary Disease (COPD)
Is the patient being assessed for COPD?
Has the patient with COPD been asked about the presence of the following factors by the respiratory nurse?
Weight loss
Effort intolerance
Waking at night
Ankle swelling
Occupational hazards
Chest pain
Was the MRC dyspnoea scale used to grade breathlessness according to the level of exertion required to elicit it?
Have patients with an MRC score of 3, 4 or 5 been offered a referral to pulmonary rehabilitation?
Has pulse oximetry been recorded to assess the need for oxygen?
Is there an up to date smoking history for the patient?
Does it include smoking pack years?
If the patient is planning to stop smoking, have they been referred to smoking cessation services?
Has the patient been given a personalized care plan which includes a self-management plan for exacerbations?
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Additional Comments
Data Collector Name & Signature
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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