Sleep Medicine Follow-Up Note (PAP Therapy Management)

Date of Service: [date]

Patient Name: [patient full name]

Provider: [provider name, credentials]

Visit Type: [in-person / telehealth]

PAP Data Source: [source] for [date range]

Reason for Visit

[Primary visit purpose such as PAP follow-up, compliance evaluation, troubleshooting, or supply renewal]

Subjective

Interval History: [Time since last sleep visit or PAP start; note major interval events such as hospitalizations, surgeries, significant weight change, or illness with dates if stated]

Symptom Response: [Snoring, witnessed apneas, daytime sleepiness, morning headaches, nocturia, and sleep quality - state whether improved, unchanged, or worsened relative to baseline; include ESS score if obtained]

PAP Experience: [Mask type and fit; pressure comfort; humidification adequacy; side effects if present such as dry mouth, nasal congestion, skin irritation, aerophagia, or claustrophobia]

Adherence Barriers: [Barriers to use if present and what patient has tried to address them] (Only include if barriers are present.)

Drowsy Driving: [Denies / Endorses] drowsy driving. (If positive, document circumstances and counseling provided.)

Objective

Vitals: [weight, BMI, blood pressure as relevant] (If telehealth, state: Vitals unavailable due to telehealth.)

Exam: [Alertness, nasal patency, oropharynx, peripheral edema as relevant] (For telehealth, state: Exam limited by telehealth.)

PAP Data Review:

• Device/Settings: [mode]; [pressure(s) or range]; [EPR/Flex setting]
• Adherence: [days used out of period]; [average hours/night]; [% nights ≥4 hours]
• Efficacy: [residual AHI with components if available]
• Leak: [leak value] – [acceptable / borderline / excessive]

(If objective PAP data unavailable: Objective adherence data unavailable; patient reports [usage pattern] but this cannot be verified. Plan to obtain download from [source] within [timeframe].)

Assessment

1. Obstructive sleep apnea on PAP therapy – [adequate / inadequate] adherence ([metrics]); residual AHI [controlled / elevated] ([value]); symptoms [improved / unchanged / worsened]. [Brief clinical interpretation linking data to symptoms]
2. [Additional active problems only if applicable, such as PAP side effects requiring intervention, adherence barriers, residual sleepiness despite adequate therapy, or treatment-emergent central apnea]

Plan

• PAP therapy: [Continue / adjust / escalate] [specific settings] – [rationale tied to data]
• Troubleshooting: [Interventions as needed such as mask refit, humidification adjustment, pressure comfort strategies, nasal therapy, or desensitization] (Only include if needed.)
• Supplies/DME: [Supplies ordered with replacement rationale; DME supplier if known]
• Follow-up: [Interval]; [what will be reviewed]; [interim contact plan]

(For compliance evaluation visits: Clinical re-evaluation performed. Patient reports [symptomatic improvement / no change]. Objective adherence report reviewed and retained in medical record.)

(If drowsy driving reported: Document safety counseling and risk mitigation plan.)