Bronchopulmonary Dysplasia Follow-Up Note

Date: [Date]

Patient: [Patient name]

DOB/MRN: [DOB / MRN]

Chronological Age: [Chronological age]

Corrected Age: [Corrected age] (If not calculable, enter "unknown.")

Visit Type: [new / established follow-up]

Location: [Clinic location]

Caregiver(s) Present: [Names and relationships]

Interpreter: [yes (language) / no]

Data Sources Reviewed: [Records and data reviewed]

Chief Concern

[Caregiver-reported reason for visit or clinician-defined purpose] (One sentence. If unclear, default to "routine BPD follow-up.")

Interval History

(Write as concise flowing prose or tight bullets summarizing changes since last pulmonary visit, or since NICU discharge if first outpatient visit.)

• [Time since last pulmonary visit or NICU discharge]
• [Major interval changes] (Support changes, hospitalizations, new diagnoses; include dates and treatments.)
• [Current respiratory symptoms] (Work of breathing, cough, wheeze, sleep symptoms, triggers.)
• [Current respiratory support and oxygen therapy] (Mode; flow/settings; schedule for day/night/naps/feeds; prescribed SpO2 targets; home monitoring approach with alarm limits.)
• [Recent exacerbations and acute care] (ED visits, hospitalizations, systemic steroids, antibiotics, viral illnesses; document dates, diagnoses, and treatments.)
• [Feeding and aspiration risk screen] (Feeding route; symptoms during feeds such as cough, choking, desaturation, or fatigue; prior swallow study results with date.)
• [Growth and nutrition] (Weight/length trajectory; intake pattern; feeding tolerance.)
• [Current respiratory medications and adherence] (Include delivery device and frequency.)
• [Immunization status and RSV prevention] (Document product name and administration date; include influenza status.)
• [Baseline BPD course summary] (First visit only: gestational age, birth weight, NICU respiratory course, BPD severity classification, discharge support settings, major comorbidities. For established patients, one-line baseline severity reference.)

Objective

• Vitals: [Vital signs] (Include SpO2 with context: room air vs on oxygen, awake vs asleep, calm vs crying.)
• Growth: [Weight, length, head circumference with percentiles or z-scores and trend]
• Exam: [Focused physical examination] (General appearance; work of breathing; breath sounds; cardiac findings if pulmonary hypertension is a concern; feeding observation if performed. For telehealth, label as limited and distinguish caregiver-reported from clinician-observed findings.)
• Data Reviewed: [Key results with dates] (Home oximetry downloads, overnight oximetry/PSG, swallow study, echocardiogram, labs. Note explicitly if information is caregiver-reported rather than from records.)

Assessment

(Problem-oriented synthesis ordered by clinical priority. For each active problem, state current status with supporting evidence. Typical problems: oxygen dependence, pulmonary hypertension, feeding/aspiration risk, growth/nutrition, reactive airway symptoms, sleep-disordered breathing.)

[Problem 1]: [Diagnosis or clinical impression]

[Assessment with key supporting data and status: improving / stable / worsening] (Include differentials if uncertainty exists.)

[Problem 2]: [Diagnosis or clinical impression]

(Repeat problem blocks as needed.)

Plan

(Organize by problem. Be specific and actionable. Include parameters, timelines, and safety guidance.)

Oxygen/Respiratory Support

• [SpO2 targets] (Specify awake/asleep if different.)
• [Weaning strategy] (Which period to wean first; step size; interval between steps.)
• [Monitoring plan] (Data to collect before next visit.)
• [Safety instructions] (When to increase oxygen; when to contact clinic; when to seek urgent care.)

Medications

• [Bronchodilator/inhaled steroid plan] (Time-limited trial vs maintenance; response criteria; stop rules.)
• [Diuretics if applicable] (Indication; continue vs taper with details.)
• [Other therapies] (Airway clearance, nebulized therapies, device technique education.)

Feeding/Aspiration

• [Aspiration risk screen result: positive / negative] (With rationale.)
• [Next diagnostic step if indicated] (e.g., VFSS referral.)
• [Interim precautions] (Positioning, pacing, thickening, route adjustments.)

Growth/Nutrition

• [Nutrition strategy] (Dietitian involvement; caloric density; supplementation.)
• [Growth monitoring plan]

Pulmonary Hypertension

(Include only if present.)

• [Coordination plan] (Echocardiogram timing; co-management with cardiology.)
• [Impact on oxygen weaning] (Whether PH modifies weaning pace or targets.)

Reactive Airway/Sleep

(Include only if applicable.)

• [Reactive airway plan] (Trigger avoidance; controller vs rescue strategy.)
• [Sleep-disordered breathing plan] (Evaluation or management steps.)

Exacerbation Action Plan

• [Sick plan for viral illness] (Home management steps; thresholds for escalation; medication adjustments.)

Prevention

• [RSV prevention] (Product name and timing for upcoming season.)
• [Influenza and routine immunizations]

Follow-up

• [Follow-up interval]
• [Data requested for next visit]