Patient COPD Checklist and Action Plan – Example


An example of a checklist and action plan to educate and encourage chronic obstructive pulmonary disease (COPD) patients to become more engaged in monitoring their health status and to improve patient-provider communication. The COPD checklist includes information for patients to think about before a medication appointment. The patient action plan lists Green, Yellow and Red Zone symptoms for COPD patients and action steps for patients when experiencing Green, Yellow or Red Zone symptoms. The action plan should be filled out by the patient’s clinician and reviewed regularly.


Appropriate for use by health care providers interacting with patients in the mHealth program.

Helpful Tips

  • Use this tool as an example for creating program-supportive educational materials.
  • Incorporate COPD zone content when following up with patients (e.g. ask patient if they have any yellow or red symptoms).
  • Use this tool as a guide for patients to understand COPD symptoms and how this relates to levels of care needed.

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