PRE POST PRE POST /100 /100 K- BILD SGRQ Psychological CRQ Dyspnoea /7 /7 K- BILD average Symptoms /7 /7 K- BILD CRQ Fatigue Breathlessness & average score Activities CRQ Emotion /7 /7 K- BILD Total /100 /100 average score Score CRQ Mastery /7 /7 /21 /21 HADS Anxiety average score /40 /40 /21 /21 CAT HADS Depression /60 /60 /65 /65 PRAISE BCKQ DISCHARGE Discharge assessment performed? Discharge Assessment date: Yes No If no, reasons did not complete Completed programme? Died Co-morbidities Became unwell DNA F/U Referred elsewhere Transport Yes No problems No contact Other ……………………………………………….. If yes, patient reported MRC Grade 1 Grade 2 Grade 3 dyspnoea score at discharge Grade 4 Grade 5 Not known Yes No Written discharge exercise plan provided? Referred to community exercise scheme Yes No Patient satisfaction questionnaire completed Yes No Comments for discharge report: Signature:
PRE POST PRE POST SGRQ /100 /100 K- BILD Psychological CRQ Dyspnoea average /7 /7 K- BILD Symptoms CRQ Fatigue average score /7 /7 K- BILD Breathlessness & Activities CRQ Emotion average score /7 /7 K- BILD Total Score /100 /100 CRQ Mastery average score /7 /7 HADS Anxiety /21 /21 CAT /40 /40 HADS Depression /21 /21 PRAISE /60 /60 BCKQ /65 /65 DISCHARGE Discharge assessment performed? Yes No Discharge Assessment date: Completed programme? Yes No If no, reasons did not complete Died Co-morbidities Became unwell DNA F/U Referred elsewhere Transport problems No contact Other ……………………………………………….. If yes, patient reported MRC dyspnoea score at discharge Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Not known Written discharge exercise plan provided? Yes No Referred to community exercise scheme Yes No Patient satisfaction questionnaire completed Yes No Comments for discharge report: Signature: