COPD Discharge Checklist

 Before Discharge (If Applicable)

☐ Establish cognitive and functional status
☐ Establish family resources
☐ Establish medication regimen
☐ Ensure knowledge of hospital visit is understood
☐ Ensure knowledge of each home medication (bronchodilators, corticosteroids,
etc.)
☐ Ensure proper technique for DPI vs. MDI with spacer, and nebulizers
☐ Ensure home oxygen is understood
☐ Ensure proper usage and understanding of home non-invasive devices
☐ Teach-back method and repeat everything discussed to ensure proper
communication and understanding
☐ Implement action plan to help patient understanding and manage of condition
☐ Educate avoiding triggers, nutrition & hydration, infection control, personal
hygiene, and immunizations
☐ Other:____________________________________________________

 Discharge Plan (If Applicable)

☐ Set up follow-up appointment with primary care physician within 7 days
☐ Set up pulmonary rehabilitation or disease management program appointment
☐ Set up appointment for smoking cessation
☐ Ensure home oxygen is set-up and available
☐ Ensure spacer, nebulizers, and other accessories are available
☐ Set up home visit for follow up within a week
☐ Provide patient with written/ printed summary of hospital stay
☐ Provide patient with written/ printed explanation of disease process and
management
☐ Provide patient with resources for rehabilitation, education, and support
groups
☐ Address family/ care givers intervention and support
☐ Address family/ care givers education on home equipment, medications,
regimen, and action plan
☐ Other:_______________________________________________________

 Follow Up (If Applicable)

☐ Make follow up at home visit within 72 hours of discharge with transition coach
☐ Reassess correct usage of MDI, Spacers, DPI, Nebulizers, etc.
☐ Check cognitive and functional ability at home
☐ Go over treatment regimen and discuss why each medication is used
☐ Check home equipment usage
☐ Assess compliance with medications and home treatments/ regimens
☐ Assess daily life, baseline and daily activities
☐ Re-educate avoiding triggers, nutrition & hydration, infection control, personal
hygiene, and immunizations
☐ Re-address action plan
☐ Re-address family/ care givers intervention and support
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☐ Re-address family/ care givers education

☐ Evaluate home transition as a whole: family views, patient views, regiments,
follow up appointments, etc.
☐ Re-address resources and availability
☐ Other:_____________________________________________________

 Maintenance (If Applicable)

☐ Develop and utilizing self-management tools
☐ Oxygen management
☐ Rehabilitation
☐ Follow-up appointments
☐ Pro-active with action plan
☐ Re-educate on new and old medications and tools whenever possible
☐ Other:______________________________________________________

 Professional Services (If Applicable)

☐ Sleep Study
☐ Pulmonary Function Test
☐ Smoke Cessation
☐ Counseling
☐ Cardiopulmonary Rehabilitation

 Other Services (If Applicable)

☐ Anxiety Screening
☐ Depression Screening
☐ Nutritional Screening
☐ QOL assessment
☐ Functional limitation assessment
☐ Mobility assessment
☐ Resources for management
☐ Other:______________________________________________________

 Patient Specific (If Applicable)

☐ Address advanced directives
☐ Ask patient for their feeling/ attitude toward everything discussed
☐ Ask patient if they have any questions or comments
☐ Ask patient for suggestions they believe would help them
☐ Other:______________________________________________________