close
lumiform
Lumiform Mobile audits & inspections
Get App Get App

Clinical Audit Questionnaire Template

Downloaded 3 times

Rated 5/5 stars on Capterra

Say goodbye to paper checklists!

Lumiform enables you to conduct digital inspections via app easier than ever before
  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 5,000 expert-proofed templates

Digitalize this paper form now

Register for free on lumiformapp.com and conduct inspections via our mobile app

  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 4000 expert-proofed templates
Rated 5/5 stars on Capterra

Clinical Audit Questionnaire Template

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
Fatigue
Occupational hazards
Chest pain
Haemoptysis
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?

Sign Off

Additional Comments
Data Collector Name & Signature
Share this template:
This template is also available in: