Asthma Evaluation/Management Note (Allergy Clinic)

Encounter Overview

Encounter Type: [Initial evaluation / Follow-up / Post-exacerbation follow-up]

Data Reviewed: [external records / pharmacy fills / prior PFTs / ED or urgent care notes / allergy testing / none] (Select all that apply; briefly specify dates or sources only if they directly inform today's decisions.)

Chief Complaint

[One-line, patient-centered reason for today's visit]

History

[Brief narrative of current symptom pattern, what prompted today's visit, and notable recent changes since last encounter including medications, exposures, infections, or barriers] (Clearly label patient-reported information; do not mix with clinician-observed findings.)

Control (past 4 weeks): [Daytime symptom frequency, night waking frequency, reliever product and use frequency, activity limitation, ACT or ACQ score if administered, overall control category: well-controlled / partly controlled / uncontrolled]

Risk (past 12 months): [Oral corticosteroid bursts with count and most recent date, ED/urgent care visits, hospitalizations, ICU admissions or intubation history, exacerbation pattern if identifiable: seasonal / viral / allergen-driven / unclear] (Use "Unknown/Not available" and note records requested if data unavailable.)

Triggers and Exposures: [Relevant allergen exposures with sensitization context, irritant exposures, other triggers] (Include home or environmental details only when relevant to management.)

Medications: [Current controller regimen: drug, strength, device, dose, frequency] [Current reliever regimen: drug, PRN instructions, typical weekly use] [Spacer or nebulizer use if applicable] (Note prior therapies and reason discontinued only if relevant to today's decisions.)

Adherence: [Patient-reported missed dose frequency, identified barriers, objective proxies if available] (When stepping up therapy, explicitly state whether adherence barriers were reviewed and addressed.)

Inhaler Technique: [Devices assessed, technique adequacy, specific errors identified, corrective education provided, teach-back outcome] (Required when control is poor or management is changing. Use "Not assessed" with rationale if expected but omitted.)

Comorbidities: [Asthma-relevant conditions addressed today: allergic rhinitis, GERD, OSA, anxiety/dysfunctional breathing, COPD overlap, other] (Include only if addressed today.)

Objective

Vitals: [RR, SpO2, weight/BMI as clinically relevant]

Exam: [General appearance and work of breathing, lung findings, upper airway/nasal exam if allergic component addressed]

Testing: [Spirometry: date, pre/post status, FEV1, FVC, FEV1/FVC with % predicted, bronchodilator response, quality grade, interpretation] [FeNO: value in ppb, ICS status at measurement, interpretation band, statement that FeNO is adjunct to clinical assessment] [Labs: absolute eosinophil count, total IgE, other relevant results] (Include only tests performed or reviewed today that inform management; omit section entirely if none.)

Assessment

Asthma: [Diagnostic confidence: confirmed with objective evidence / probable / uncertain] [Current control category with supporting data] [Risk profile including exacerbation history and SABA overuse concerns] [Phenotype modifiers if relevant: allergic / type 2 high / exercise-induced] [Modifiable contributors: technique errors / adherence barriers / exposures / comorbidities] (If control is poor, explicitly state primary driver and what was done about it.)

Secondary problems: [Problem name with brief status and relevance to asthma management] (Include only conditions addressed today.)

Plan

Pharmacotherapy: [Guideline framework: GINA / NAEPP] [Current step and new step if changed] [Controller instructions: drug, strength, device, puffs, frequency] [Reliever instructions: drug, puffs, PRN guidance] (For step-up, document adherence and technique were assessed. For step-down, document duration of stability. Note shared decision-making factors as relevant.)

Action Plan: [Written asthma action plan: provided / reviewed / updated / not provided] [Yellow zone instructions per clinic protocol]

Interventions: [Technique training with teach-back outcome, adherence supports, access solutions as applicable]

Trigger Mitigation: [Allergen-specific interventions when sensitization and exposure support them, smoking/vaping cessation counseling if applicable]

Comorbidity Management: [Brief plan for conditions addressed today]

Follow-up: [Timing based on control and recent changes, parameters to reassess, return precautions]

(Handling missing information: Omit sections not relevant to today's visit. Use "Not assessed" for expected elements when omitted. Use "Unknown/Not available" when data exist but were inaccessible. Label patient-reported information; do not present assumptions as facts.)