Date: <TodaysDate>(Ask your doctor to review each year with your care plan)

Patient Name: <PtFullName>	Date of Birth: <PtDoB>	
GP Name: <DrName>	GP Phone:  <DrPhone>	
Nurse Name: <Nurse name>	Nurse Phone: <Nurse Phone> 	

Annual Influenza Immunization - Date: <Influenza date given>	
Last Pneumoccal Immunisation - Date: <Pneumococcal date given>	
Feeling your usual self (easy to breathe)	
I can do my usual activities
Sleeping as usual	Taking usual medicine
Usual amount of phlegm	MY FEV1 IS: <FEV1> L 
Date last spirometry performed <Date Spirometry last performed>	
ACTION: Continue taking your usual medicines as listed below.	
Usual Medicines: 
<SelectedRx>	
Oxygen:  <Oxygen>	<Oxygen Setting or L/Min> L/min 	Oxygen:  <Oxygen hrs/day> hrs/day 	CO2 RETAINER: <CO2 retainer ?> 	
Feeling harder to breathe / Feeling sick 	
More phlegm or thicker than usual	More coughing	Not sleeping well	
	Loss of appetite	Not much energy	
ACTION: Follow plan below for extra medicines. Plan your day, get rest, relax, use breathing techniques, huff and cough to clear phlegm as required.  	
My extra medicine	Colour of device	How many puffs or tablets	How often	
<Harder to Breathe Extra Medicine1>	<Harder to breathe ExtraMedicine1-Colour>	<Harder to Breathe ExtraMedicine1-Dose>	<Harder to Breathe ExtraMedicine1-Frequency>	
Feeling sick:		
Taking reliever medicines 3-4 hourly, but not getting adequate relief.
ACTION: Start taking prednisolone. Contact your Doctor/Nurse/Health Worker.  	
Prednisolone*: 
<Feeling Sick Action>	Prednisolone Strength <Prednisolone Strength  (in mg)> mg	
Take  <tablets per day> each day	
Take for <Number of days to take prednisolone> days	
A change in colour and/or volume of phlegm. Fever
ACTION: START TAKING ANTIBIOTIC   AS WELL AS PREDNISOLONE. CONTACT YOUR DOCTOR/NURSE 	
Antibiotics*: 
<Antibiotic Name>	Antibiotic strength <Antibiotic Strength>	
Take <Antibiotic doses per day>   	
Take for <Days on Antibiotic> days 	
 <Second Antibiotic if required>	 <Second Antibiotic Strength>	 <Doses per day of second antibiotic if required> 	 <Number of days to take second antibiotic if required> 	
* GP to fill in if prescribed.
Not feeling good (trouble breathing and wheezing)	
Difficulty sleeping/ woken easily	Blood in your phlegm	Swollen ankles	|ACTION: CONTACT DR	
Very short of breath at rest	High fever	Chest pain	l Phone an Ambulance 000	
Confused, slurring of speech	Drowsy	Afraid/scared	|Phone an Ambulance 000
 show them this plan	
CAUTION: Ambulance/Paramedics: Oxygen supplementation to maintain SpO@ 92% max (exceeding this risks hypercapnia)	

Resources available via Lung Foundation Australia - Contact to order your copy. 
Better Living with COPD - Patient Guide 
Better Living with Your Lung Disease DVDs
1800 654 301 | www.lungfoundation.com.au | enquiries@lungfoundation.com.au