COPD Follow-up Note: Structure and Sections
COPD return visit per GOLD 2024 guidelines. Notermed's built-in COPD 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 COPD Follow-up Note contains
7 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Interval History
- Dyspnea level, with mMRC grade or CAT score when mentioned
- Exertional tolerance and functional limitations
- Cough and sputum: volume, color, change from baseline
- Exacerbations: frequency, severity, hospitalizations
- Antibiotic or corticosteroid courses
- Smoking status, when mentioned
- 2
Spirometry / Pulmonary Function
- FEV1 as percent predicted, FVC, FEV1/FVC ratio
- GOLD grade as assigned
- 3
Oxygen Therapy
- Home oxygen flow rate
- Hours per day
- Delivery device
- 4
Medications
- Current bronchodilator regimen
- Rescue use frequency
- Any change made today
- 5
Physical Examination
- Vital signs including oxygen saturation at rest
- Chest findings
- 6
Assessment
- GOLD grade and stability, as stated
- 7
Plan
- Medication adjustments
- Pulmonary rehabilitation
- Smoking cessation
- Oxygen changes
- Follow-up
This format is structured around GOLD 2024. 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 far can you walk before the breathlessness stops you, and did you need antibiotics at any point this year?
Patient
Two blocks on the flat, the same as before, and I stop on the hill behind the house. One course of antibiotics in the spring, no hospital stay. The morning cough is the same, and it stays clear.
Doctor
That keeps you at mMRC grade two, and you are stable since your last visit. Let us leave the inhalers as they are and get you started on pulmonary rehab.
Patient
I can do that.
Doctor and patient speech separated automatically.
Interval History: Dyspnea unchanged at two blocks on level ground, mMRC grade 2. Morning cough unchanged, sputum clear. One course of antibiotics in the spring, without hospitalization.
Medications: Current bronchodilator regimen continued, no change made today.
Assessment: COPD stable since the last visit.
Plan: Continue the current bronchodilator regimen. Pulmonary rehabilitation to be arranged.
Illustrative example, not a real patient.
Questions about the COPD Follow-up Note
What sections does the COPD follow-up note contain?
Seven: Interval History, Spirometry and Pulmonary Function, Oxygen Therapy, Medications, Physical Examination, Assessment and Plan.
Does the note record an mMRC grade or a CAT score?
When one was mentioned. The interval history records the dyspnea level with the mMRC grade or CAT score where it is stated, along with exertional tolerance, cough and sputum, exacerbations, antibiotic or corticosteroid courses, and smoking status where it came up.
Which guideline is the COPD template built around?
GOLD 2024. That is the framework the section order and the wording follow, and the assessment reports the GOLD grade and stability as the clinician stated them rather than working a grade out on its own.
Are the spirometry numbers filled in from the chart?
No. The spirometry section reports FEV1 as percent predicted, FVC, the FEV1 over FVC ratio and the GOLD grade as assigned, from what was said or read out in the visit. The draft is built only from the visit.
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 COPD 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.