Pulmonary Rehabilitation Referral Note

Date: [date of note] | Patient: [full name, DOB, MRN] | Referring Provider: [name, credentials, clinic/service] | Receiving Program: [facility name/location if known] | Urgency: [routine / expedited] (If expedited, include brief rationale.)

Referral Indication

[Referral indication narrative] (Write a concise paragraph of 4–6 sentences establishing medical necessity for pulmonary rehabilitation. Include: COPD diagnosis and current stability status with date of most recent exacerbation or hospitalization if applicable; specific functional limitations quantified where possible including walking tolerance, stair tolerance, and ADL restrictions; primary symptom drivers such as dyspnea, fatigue, or deconditioning; and why usual care is insufficient despite optimized therapies. For post-hospitalization referrals, describe functional decline and readmission risk. Anchor necessity to measurable, patient-reported limitations.)

Clinical Summary

COPD Diagnosis: [Diagnostic label with phenotype if known; smoking history with pack-years and current status; quit date if applicable; approximate date of diagnosis]

Spirometry: [Post-bronchodilator FEV1/FVC, FEV1 % predicted, GOLD grade 1–4, test date] (If unavailable, state "Spirometry not available" and do not assign GOLD grade.)

Symptoms: [mMRC dyspnea score with anchor statement and/or CAT score] (If not obtained, state "not measured.")

Exacerbation History (12 months): [Number of moderate exacerbations requiring steroids/antibiotics; number of severe exacerbations requiring ED/hospitalization; ICU admission or mechanical ventilation if applicable; date of most recent exacerbation]

Baseline Function: [Patient-reported walking tolerance with distance and terrain; stairs tolerance; ADL limitations requiring rest or assistance; assistive device use; falls risk] (If formal testing available, include 6MWT distance, SpO2 nadir, oxygen flow used, and test date. If no formal testing, state "not performed prior to referral.")

Oxygenation: [Resting SpO2 on room air or oxygen; exertional desaturation pattern if known; home oxygen prescription with flow rates for rest/exertion/sleep and delivery method; NIV/CPAP use and adherence if applicable] (If oxygen status unknown, state explicitly.)

Relevant Comorbidities: [Conditions affecting exercise tolerance or safety: cardiac disease, musculoskeletal/neurologic limitations, anxiety/panic with dyspnea, metabolic conditions, frailty] (Do not copy entire problem list.)

Safety and Contraindications

Absolute Contraindications: [none identified / specify findings] (Document if present: unstable angina, recent MI without clearance, uncontrolled arrhythmia, acute infection, suspected DVT/PE, severe uncontrolled hypertension, unexplained exertional syncope.)

Relative Contraindications or Modifications Needed: [none identified / specify relevant limitations and required modifications] (Consider musculoskeletal limitations, severe anxiety with exertion, cognitive impairment, fall risk, severe anemia, brittle diabetes.)

Clearance Requests: [none needed / specify pending clearances or evaluations] (Include cardiology clearance with indication, pending stress test or echo, oxygen titration evaluation request if applicable.)

Current Management

Inhaled Regimen: [LAMA/LABA/ICS combination, nebulizers, rescue inhaler frequency]

Recent Treatments: [Systemic steroids or antibiotics with dates if applicable]

Smoking Status: [Current status and cessation supports in place]

Adherence Barriers: [Cost, inhaler technique, transportation, language, or other barriers if present] (Omit if none identified.)

Referral Order

Service: Outpatient pulmonary rehabilitation

Diagnoses: [Primary diagnosis with GOLD grade if spirometry-confirmed; relevant secondary diagnoses]

Requested Start: [within 2–3 weeks / upon discharge clearance / earliest available]

Modality: [center-based / telerehabilitation / hybrid / program discretion]

Special Instructions: [Oxygen titration needs with target SpO2 range; exercise restrictions or orthopedic precautions; communication requests] (Omit if none.)

Follow-Up: [Medical follow-up provider during rehab; when to contact referring provider; request for baseline and discharge outcomes data including 6MWD and symptom scores]