Asthma Follow-Up Note (with Action Plan)

(Use explicit timeframes throughout. Do not autopopulate normal findings—document only what was actually assessed. Omit sections not relevant to today's encounter. For clinically relevant but unobtained information, write "Not assessed" with brief reason. For the action plan, do not leave dosing fields blank—either provide explicit instructions or document that the plan cannot be finalized with interim instructions and follow-up plan.)

Date/Time: [date and time] Patient: [name, age, pediatric/adolescent/adult] Visit Type: Asthma Follow-Up with Action Plan Update Clinician: [clinician name and credentials]

Chief Complaint

[Brief patient-centered reason for visit] (One line; a concise direct quote may clarify the patient's concern or goals.)

Interval History

[One-sentence summary of asthma status since last visit, including approximate date of last visit]

Symptom Control (past 4 weeks):

• [Daytime symptom frequency] (Source: [patient / caregiver / other])
• [Nighttime awakening frequency]
• [Reliever use frequency, excluding pre-exercise prophylaxis]
• [Activity limitation: none / mild / moderate / severe]

Exacerbations/Risk (since last visit and/or past 12 months): [Oral corticosteroid bursts with approximate dates; ED/urgent care visits; hospitalizations; suspected triggers if identified] (Use "None" if no exacerbations.)

Current Regimen & Adherence: [Controller and reliever medications with device, strength, prescribed frequency; actual use pattern and adherence characterization with source; side effects or tolerability concerns]

Inhaler Technique: [Device(s) evaluated; observed vs verbally reviewed; errors identified; corrections taught; teach-back result] (If not assessed but clinically indicated, document "Not assessed" with reason and plan.)

Triggers: [Known or suspected triggers currently active or relevant to today's visit] (Omit if no trigger discussion occurred.)

Objective

Vitals: [relevant vitals as obtained]

Exam: [Focused lung exam: wheeze character/location, aeration, work of breathing; upper airway if rhinitis suspected] (For telehealth, explicitly note examination limitations.)

Spirometry: [Date; pre/post-bronchodilator status; FEV1, FVC, FEV1/FVC with absolute and % predicted; quality grade; interpretation with comparison to prior if available] (Include only if performed or reviewed today; otherwise omit.)

Assessment

Asthma Control: [well controlled / partly controlled / uncontrolled] (Explicitly cite supporting criteria from history addressing both impairment and risk.)

Treatment Step: [Current step level] — [step up / step down / maintenance] (If using SMART/MART regimen, state clearly.)

Contributors to Poor Control: [technique / adherence / ongoing trigger exposure / comorbidities / diagnostic uncertainty] (Include only when asthma is not well controlled; otherwise omit.)

Plan

Medications: [Controller and reliever changes with specific medication, device, strength, and frequency; include explicit criteria and dosing for pre-exercise prophylaxis or home oral corticosteroid initiation if applicable] (Specify medications by name rather than "continue current.")

Technique/Adherence Interventions: [Teaching performed; spacer or device provided; teach-back result; adherence supports initiated] (Omit if not addressed.)

Follow-up: [Timing for next visit; planned spirometry with timing if applicable; return precautions including worsening symptoms, frequent reliever use, red-zone criteria]

Referrals: [Referrals made or discussed today] (Include only if applicable.)

Asthma Action Plan

Action plan updated: [date] Reviewed with: [patient / caregiver] Delivered via: [print / portal / other]

Patient: [name] Personal Best PEF: [value and date / Not established / Not using PEF monitoring] Emergency Contact: [clinician phone and after-hours instructions]

GREEN ZONE (Doing Well):

• [Symptom criteria for green zone]
• [Daily controller medication(s) with exact dosing]
• [Pre-exercise medication and timing, if applicable]

YELLOW ZONE (Getting Worse):

• [Symptom criteria and/or PEF range]
• [Quick-relief instructions: medication, dose, frequency]
• [Controller adjustment if applicable: medication, dose change, duration]
• [Time to reassess and actions if not improving, including who to contact]
• [Maximum dose ceiling if relevant]

RED ZONE (Medical Alert):

• [Symptom criteria and/or PEF threshold]
• [Immediate medication steps]
• [When to call clinician; when to go to ED; when to call 911]