Clinical Audit Questionnaire Template - Free Download

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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

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?

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Additional Comments

Data Collector Name & Signature

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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.