Stage 2: Record the relevant information

Aim:

Stage 2 involves repeating or undertaking spirometry for the first time if this is not on record and recording the relevant information in the patient notes.

Rationale:

NICE guidance and quality standards state that all patients over the age of 35 who present with symptoms of COPD should have a post-bronchodilator test to confirm their diagnosis. Accurate diagnosis, following history and examination, can only be achieved by confirmation with post-bronchodilator spirometry showing an FEV1/FVC ratio less than 0.7. Otherwise it could be something else, and currently the data suggests this may be 25% of COPD registers.

NICE recommends that at the time of initial diagnostic evaluation, in addition to spirometry, all patients should have a chest X-Ray to exclude other pathologies.

What is involved?

This stage is about getting the diagnosis right. This means reviewing the patient record to confirm they a history and clinical presentation consistent with COPD, as well as spirometric evidence consistent with COPD i.e. an FEV1/FVC ratio below 0.7.

How will I show improvement?

Improvement will be shown where more patients have received the correct diagnosis and evidence for this diagnosis is correctly documented. This will be represented as an improvement report demonstrating change from the baseline (the data date that you started this project).

Those with good evidence of COPD will be given the right code and this will be shown in your report once it's done. Those that do not meet the diagnostic criteria, whether this is because there is good evidence that they don't have it, or because there is insufficient, or poor-quality evidence to them having it, may require further investigation. This is described in further detail in stage 2.

© Institute of Clinical Science and Technology.

Email: admin@clinicalscience.org.uk

Tel: 02920 092828