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1September 2017
Nurse Care Manager Template Review
Step 1: Service Development
ED or Hospital Discharge
RN Visit
3 weeks 2 months(45 minute visit) (15 minute visit)
Telephone Appt.
Spirometry
3 months(30 minute visit)
Respiratory Therapy
48 hr RN Call
3September 2017
Nursing 48 Hour Post Hospital Discharge Call Template
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Objectives
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Service ReferralPatient recently discharged with COPD
diagnosis per ICD‐10 code
Patient requires onlyCOPD follow‐up
Schedule COPD CARE service visit Goal: 3 weeks post‐discharge
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Service ReferralPatient recently discharged with COPD
diagnosis per ICD‐10 code
Patient requires onlyCOPD follow‐up
Patient requires COPD follow‐up and follow‐up for additional disease state not managed by PACT pharmacist
Schedule COPD CARE service visit Goal: 3 weeks post‐discharge
Schedule PCP Visit
Service Review
ED or Hospital Discharge
RN Visit
3 weeks 2 months(45 minute visit) (15 minute visit)
Telephone Appt.
Spirometry
3 months(30 minute visit)
Respiratory Therapy
48 hr RN Call
Nursing 3 week Clinic Visit Template
12September 2017
Nursing 3 week Clinic Visit Template
13September 2017
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18September 2017
Nursing Patient Education Documentation Template
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ED or Hospital Discharge
PharmDVisit
3 weeks 2 months(45 minute visit) (15 minute visit)
Telephone Appt.
Spirometry
3 months(30 minute visit)
Respiratory Therapy
48 hr RN Call
Service Review
2 month Telephone Template
Goals of visit:1. Assess for symptom improvement or changes since 30‐day
visit with updated CAT score
2. Reinforce med adherence
3. Ensure that referrals placed at 30‐day visit have been put into place
4. Assess use of COPD Action Plan. Ensure patient aware they should call prior to using antibiotic or steroid therapy
Previous notes to review:1. Respiratory Therapy Inpatient Note • Inhaler technique information, adherence, rescue inhaler use, patient‐preferred referrals
2. Nursing 48‐hr discharge note• Symptom assessment post‐discharge, interest in referrals,
adherence, inhaler technique
3. 3‐week visit PharmD and RN note• Assessment an Plan moving forward
PharmD RNOR
41September 2017
Nurse Care Manager Template Review
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