Cystic Fibrosis Multidisciplinary Clinic Note

Date: [date]

Patient: [name, age, MRN]

Encounter Type: [routine quarterly / post-exacerbation follow-up / annual review / urgent]

Team Present: [attending, APP/fellow, RT, dietitian, SW, others as applicable]

CF Clinical Snapshot

(Compact, stable reference; update only when changes occur. Use "unknown" rather than omitting when genotype or baseline FEV1 are not available.)

• Genotype: [CFTR mutations or "unknown"]
• Modulator: [current agent and start date / "not on modulator therapy"]
• Baseline FEV1: [personal best with date; recent baseline with date / "unknown"]
• Chronic Microbiology: [dominant pathogens; special organisms if present]
• Key Comorbidities: [pancreatic insufficiency; CFRD status; liver disease; enteral feeds; oxygen/NIV; transplant status as applicable]
• Allergies/Intolerances: [major medication allergies]

Chief Concern & Interval History

[Visit reason and patient-stated priorities]

[Interval events and healthcare utilization since last CF clinic visit: exacerbations, antibiotic courses with dates and response, hospitalizations, ED visits, hemoptysis events] (If none reported, explicitly state patient reports no exacerbations since last visit. If not assessed, state "Exacerbation history since last visit not assessed today.")

[Respiratory symptoms: cough, sputum changes, dyspnea, wheeze, exercise tolerance, oxygen needs] (Include brief patient quotes only when they drive clinical decisions.)

[Airway clearance regimen: current modality, prescribed vs actual frequency, barriers] (Safety-critical; if not reassessed today, state "ACT regimen not reassessed today.")

[Inhaled/maintenance therapies: mucolytics, inhaled antibiotics and cycling status, bronchodilators, chronic azithromycin; patient-reported adherence]

[Modulator therapy: current agent, adherence, side effects, LFT monitoring status] (If monitoring overdue or abnormal, document explicit follow-up actions. If not reviewed, state "Modulator monitoring status not reviewed today.")

[Nutrition/GI: appetite, weight trajectory, stool pattern, PERT dosing and symptoms guiding titration, tube feed tolerance if applicable]

[Endocrine: CFRD management or screening status, OGTT timing if due]

[Psychosocial: depression/anxiety screening status with scores or reason for deferral, adherence barriers, social determinants affecting care]

Objective

(Include only data obtained or reviewed today. Do not infer absent findings.)

• Vitals/Anthropometrics: [temp, HR, BP, RR, SpO2; height, weight, BMI; weight change since last visit] (Include percentile if pediatric.)
• Exam: [pertinent findings: general appearance, respiratory effort, breath sounds, clubbing, abdominal exam, other relevant systems]
• Spirometry: [FEV1 and FVC with %predicted; quality/limitations; comparison to baseline] (If not performed, state "not performed" with brief reason.)
• Cultures: [most recent respiratory culture date, specimen type, organisms, key susceptibilities; chronic colonization status] (If pending, state "pending." If not obtained, state "not performed" with brief reason. Do not infer negative results.)
• Labs/Imaging: [relevant results reviewed today with dates: LFTs, vitamin levels, A1c, imaging as applicable] (Omit if not reviewed.)

Multidisciplinary Team Notes

(Include entries only for disciplines that participated. Omit disciplines that did not see the patient.)

RT

Assessment: [ACT technique assessment; device use; inhalation technique]

Recommendations: [device/technique modifications; regimen adjustments; coaching provided]

Dietitian

Assessment: [anthropometric interpretation vs targets; caloric/protein needs; PERT dose evaluation; GI symptom review]

Recommendations: [caloric strategy; PERT adjustments; vitamin/mineral changes; GI management]

Social Work

Assessment: [screening results or deferral reason; adherence barriers; social determinants impacting care]

Recommendations: [referrals/resources provided; follow-up actions and timelines]

Assessment & Plan

(Problem-oriented format. For each active problem, provide a 1–2 sentence status summary followed by a bulleted plan with specific actions, responsible parties, and timeline. Include contingency instructions for concerning symptoms. Add or remove problems as applicable.)

[Problem 1]

[Status summary integrating subjective and objective findings]

• [Plan item: action, responsible party, timeline]
• [Contingency/safety instructions if applicable]

[Problem 2]

[Status summary]

• [Plan item: action, responsible party, timeline]

(Consider: CF lung disease status; active/recent pulmonary exacerbation; airway clearance optimization; CFTR modulator therapy and safety monitoring; nutrition/weight and PERT adequacy; CFRD or screening; mental health; adherence/access barriers.)

Orders: [cultures, labs, imaging, referrals ordered today]

Follow-up: [timeframe for next visit and triggers for earlier contact]

Patient Instructions: [plain-language summary of regimen changes and safety counseling]