Asthma Follow-up Note: Structure and Sections
Asthma return visit per GINA stepwise management. Notermed's built-in Asthma Follow-up Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the Asthma Follow-up Note contains
7 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Interval History
- Daytime symptom frequency per week
- Nighttime awakenings
- Exercise limitation
- Need for rescue therapy
- Rescue inhaler (SABA) use per week, and triggers identified
- Exacerbations: hospitalizations, ED visits, oral corticosteroid courses
- 2
Asthma Triggers
- Triggers identified or suspected
- Allergens, exercise, cold air, GERD
- Occupational exposures and viral infections
- 3
Inhaler Technique & Adherence
- Adherence to controller therapy
- Technique issues noted
- 4
Medications
- Controller and rescue medications
- Device type, dose, and frequency
- Any change made today
- 5
Physical Examination
- Vital signs including oxygen saturation
- Lung auscultation findings
- 6
Assessment
- Control classification: well-controlled, partly controlled, or uncontrolled
- 7
Plan
- Medication adjustments
- Trigger management
- Action plan review
- Referrals
- Follow-up interval
This format is structured around GINA. That is the framework the section order and the wording follow. It is not a statement that a finished note meets any standard, which is a judgment only the clinician signing it can make.
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
From conversation to draft
Doctor
How often have you reached for the rescue inhaler since we last met, and has anything woken you at night?
Patient
About twice a week, usually after I have been out in the cold. Nothing at night, and I have not needed a steroid course or the ED.
Doctor
Twice a week with no night symptoms is well-controlled, so we hold the step you are on. Try a scarf over your mouth in the cold. How is the controller itself going?
Patient
I take it most mornings, but I forget the evening dose fairly often.
Doctor and patient speech separated automatically.
Interval History: Rescue inhaler use about twice weekly, associated with cold air exposure. No nighttime awakenings. No ED visit and no oral corticosteroid course since the last visit.
Inhaler Technique & Adherence: Controller taken most mornings; evening dose frequently missed.
Assessment: Asthma well-controlled on the current controller step.
Plan: Continue the current controller step. Cold air avoidance advised.
Illustrative example, not a real patient.
Questions about the Asthma Follow-up Note
What sections does the asthma follow-up note contain?
Seven: Interval History, Asthma Triggers, Inhaler Technique and Adherence, Medications, Physical Examination, Assessment and Plan.
Is the asthma template structured around a guideline?
It is structured around GINA stepwise management, which is what the section order and the wording follow. That is not a claim that a finished note meets any standard; only the clinician signing it can make that call.
What does the interval history capture?
Daytime symptom frequency per week, nighttime awakenings, exercise limitation, the need for rescue therapy, rescue inhaler use per week with the triggers identified, and exacerbations: hospitalizations, ED visits and oral corticosteroid courses.
How is control classified?
The assessment records the control classification the clinician stated, as well-controlled, partly controlled or uncontrolled. Notermed does not grade control on its own.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the Asthma Follow-up Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.