4. Key visit elements — in addition to the Respiratory assessment

In addition to the full Respiratory assessment (breath sounds, respiratory rate and effort, cough, and general findings documented there), the COPD overlay adds each visit:

• The three cardinal symptoms measured against the interval — whether dyspnea, sputum volume, and sputum purulence are increased, unchanged, or improved since the last visit, stated in those terms rather than as “baseline.”
• SpO₂ on the ordered oxygen flow, recorded with the flow (e.g. “SpO₂ 91% on 2 L/min”), and whether the oxygen requirement has changed.
• Work of breathing — accessory-muscle use, pursed-lip breathing, and the ability to speak in full sentences.
• Sputum color, volume, and consistency, and any change.
• Rescue-inhaler or nebulizer frequency over the interval against the ordered frequency.
• Inhaler and spacer technique on direct observation, device by device, and oxygen-delivery-system check (tubing, flow, humidification, cannula skin — cross-reference Nose/Sinuses).
• The current GOLD group and the exacerbation history in the past year (GOLD E denotes at least one moderate or severe exacerbation per year), and smoking status.
• The action-plan step the patient is on (green / yellow / red) and adherence to it.
• Dyspnea-related anxiety and its effect on function (cross-reference Anxiety/Coping).