Document the COPD-specific skilled surveillance and management each day:
Respiratory rate, effort (accessory-muscle use, pursed-lip breathing), and SpO₂ against the ordered oxygen parameters (often a target range such as 88–92%).
Cough and sputum (color/amount/change — a purulence change may signal exacerbation), lung sounds (wheeze, diminished air movement), and dyspnea on exertion.
Response to bronchodilators/steroids, inhaler/nebulizer technique, and activity tolerance.
MDS-supportive data
Oxygen and respiratory treatments are coded in MDS Section O0110, respiratory medications/steroids in Section N, dyspnea in Section J, and the COPD diagnosis in Section I. The record must document the oxygen setting/response, the treatments, and the assessment so the MDS is supported.
