CPAP / Sleep Apnea Follow-up Note: Structure and Sections
Sleep apnea / CPAP therapy review per AASM guidelines. Notermed's built-in CPAP / Sleep Apnea 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 CPAP / Sleep Apnea Follow-up Note contains
6 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Interval History
- CPAP, BiPAP, or ASV adherence: average hours per night
- Percentage of nights used, from device data
- AHI or residual AHI on therapy, from the device download
- Daytime sleepiness, with ESS score when stated
- Snoring, witnessed apneas, nocturnal awakenings, non-restorative sleep
- 2
Device Data
- Device type and current pressure settings
- Mask type
- Compliance and leak data
- 3
Medications
- Sedatives or other medications affecting respiratory drive
- 4
Physical Examination
- Vital signs including oxygen saturation
- BMI or weight change, when documented
- 5
Assessment
- Severity of the sleep apnea
- How effective the current therapy is
- 6
Plan
- Pressure adjustments and mode change
- Mask change
- Weight management
- Repeat study
- Referrals
- Follow-up
This format is structured around AASM. 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
The download has you on it 28 of the last 30 nights, about seven hours a night, with a residual AHI of 3.1. Your Epworth today is 6, down from 13.
Patient
That fits. I put it on at eleven and it stays on all night. The nasal pillow mask is comfortable and I do not notice any leak.
Doctor
Then the therapy is working well at this pressure. We leave it where it is and keep the same mask, and I will see you in six months.
Patient
That works for me.
Doctor and patient speech separated automatically.
Interval History: CPAP used 28 of the last 30 nights, averaging about 7 hours per night. Residual AHI 3.1 on therapy. Epworth Sleepiness Scale 6, down from 13.
Device Data: Nasal pillow mask, reported comfortable. No leak noticed by the patient.
Assessment: Sleep apnea therapy working well at this pressure.
Plan: Continue the current pressure settings and the same mask. Follow up in six months.
Illustrative example, not a real patient.
Questions about the CPAP / Sleep Apnea Follow-up Note
What sections does the CPAP follow-up note contain?
Six: Interval History, Device Data, Medications, Physical Examination, Assessment and Plan.
Where do the adherence numbers in the note come from?
From the visit. The interval history records the average hours per night, the percentage of nights used and the residual AHI on therapy as they were read out or dictated from the device download, and the draft is built only from what was said.
Which guideline does the CPAP template follow?
AASM. The section order and the wording follow it, and the assessment records the severity of the sleep apnea and how effective the current therapy is as the clinician stated them.
Is an Epworth score recorded?
Where it is stated. The interval history records daytime sleepiness with the ESS score when one was given, along with snoring, witnessed apneas, nocturnal awakenings and non-restorative sleep.
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 CPAP / Sleep Apnea 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.