REFERRAL & ASSESSMENT Date of receipt Initial Assessment of referral: date: Elective Post-AECOPD Other: Referral pathway: Referred from: Secondary Care GP/practice team Community Services Referred by: Consultant/clinical team Specialist COPD team GP Nurse Other: If no, what was the reason? PR start date offered? Clinically unsuitable Patient declined Yes No Patient unable to attend Not recorded Number of sessions scheduled: If yes, PR start date: Number of sessions completed: Site/Venue: Type of Programme: [Site A] [Site B] [Site C] Rolling Cohort Other Previously attended a PR programme in the last year? YES NO If yes, completed programme? YES NO Supplemental oxygen given during exercise Yes No Main Diagnosis COPD Asthma Alpha 1 antitrypsin deficiency Bronchiectasis Hyperventilation Respiratory Failure PCD Dysfunctional Breathing Lung Cancer ABPA Pneumonia Hyperventilation OSA IPF IP (Idiopathic Interstitial Pneumonia) NSIP Sarcoidosis ILD (Interstitial Lung Disease) HP (Hypersensitivity Pneumonitis) unknown/other Significant Comorbidities TIA CVA Vascular CKD size ……... I Diabetes II Obesity Metabolic Cachexia disease (UL or LL) R/A A/S(Ankylosing CFS(Chronic Fatigue Spondylitis) M/S (UL/LL) Syndrome) LBP(Lower back pain)
REFERRAL & ASSESSMENT Date of receipt of referral: Initial Assessment date: Referral pathway: Elective Post-AECOPD Other: Referred from: Secondary Care GP/practice team Community Services Referred by: Consultant/clinical team Specialist COPD team GP Nurse Other: PR start date offered? Yes No If no, what was the reason? Clinically unsuitable Patient declined Patient unable to attend Not recorded If yes, PR start date: Number of sessions scheduled: Number of sessions completed: Type of Programme: Rolling Cohort Other Site/Venue: [Site A] [Site B] [Site C] Previously attended a PR programme in the last year? YES NO If yes, completed programme? YES NO Supplemental oxygen given during exercise Yes No Main Diagnosis COPD Asthma Alpha 1 antitrypsin deficiency Bronchiectasis Hyperventilation Respiratory Failure PCD Dysfunctional Breathing Lung Cancer ABPA Pneumonia Hyperventilation OSA IPF IP (Idiopathic Interstitial Pneumonia) NSIP Sarcoidosis ILD (Interstitial Lung Disease) HP (Hypersensitivity Pneumonitis) unknown/other Significant Comorbidities Vascular size ……... TIA CKD CVA Metabolic I disease Diabetes II Cachexia Obesity M/S (UL or LL) (UL/LL) R/A CFS(Chronic Fatigue Syndrome) LBP(Lower back pain) A/S(Ankylosing Spondylitis)
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