Pulmonology Note: Structure and Sections
Pulmonary, Critical Care & Sleep Medicine encounter note. Notermed's built-in Pulmonology 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. In the app the format is listed as Pulmonologist Notes.
What the Pulmonology Note contains
14 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Chief Complaint (CC)
- A short reason for the visit
- For example sleep study, pulmonary nodules, CPAP compliance review
- 2
History of Present Illness (HPI)
- Referral source
- Snoring, witnessed apnea, daytime fatigue
- Dyspnea, cough, sputum, hemoptysis
- Sleep schedule and sleep quality
- Study or test results the clinician reviewed aloud
- On follow-up: interval symptoms, device and mask use
- On follow-up: current compliance metrics and AHI
- 3
Past Medical History (PMHx)
- Relevant medical history, where provided
- 4
Past Surgical History (PSHx)
- Prior surgery, where provided
- 5
Family History (FHx)
- Relevant family history, where provided
- 6
Social History
- Smoking status: current, former, or never
- Vaping, alcohol, drug use
- Pack-years, only when given or directly calculable
- 7
Review of Systems (ROS)
- General, HEENT, Cardiovascular, Pulmonary
- Gastrointestinal, Genitourinary, Musculoskeletal
- Neurological, Psychiatric
- Only the systems raised, with the findings actually stated
- 8
Medications
- Medications stated aloud or in an attached list
- 9
Allergies
- Allergies as stated
- No known allergies only when someone said so
- 10
Vitals
- BP, HR, RR, temperature
- Height, weight, BMI
- SpO2 on room air or supplemental oxygen, with liter flow
- 11
Physical Exam
- By system: GEN, NECK, RESP, CV
- GI, DERM, EXT, NEURO
- Only findings actually stated or dictated
- 12
Results / Diagnostics
- Labs
- PFTs: FEV1, FVC, FEV1/FVC, TLC, RV, DLCO, 6-minute walk
- Imaging: chest X-ray or CT, with the report impression preserved
- Sleep study: recording and sleep time, apneas and hypopneas
- AHI on 3% (AASM) and 4% (CMS) criteria, oximetry nadir, severity
- 13
Assessment
- A problem list of the diagnoses the clinician stated
- ICD-10 codes flagged for billing verification
- Severity, only where the clinician stated it
- 14
Plan
- Grouped by problem, numbered
- Sleep: device start and settings, pressure change, switch to BiPAP
- Sleep: titration or BiPAP ASV study, mask and settings, driving advice
- Sleep: weight loss and GLP-1 discussion
- Pulmonary: repeat CT follow-up, at the Fleischner interval when stated
- Pulmonary: ABG, complete PFTs with lung volumes and diffusion
- Pulmonary: tobacco cessation, bronchodilator benefit discussion
- Follow-up interval
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.
Questions about the Pulmonology Note
What sections does the pulmonology note contain?
Fourteen, from Chief Complaint and History of Present Illness through the medical, surgical, family and social histories, Review of Systems, Medications, Allergies, Vitals, Physical Exam and Results and Diagnostics, to the Assessment and Plan.
Does the note report an AHI on both AASM and CMS criteria?
Where the clinician states them. The results section reports the recording and sleep time, apneas and hypopneas, the AHI on the 3 percent AASM and 4 percent CMS criteria, the oximetry nadir and the severity. Those are figures a finished note reports, not a framework this format is built on.
Which pulmonary function values does it record?
FEV1, FVC, the FEV1 over FVC ratio, TLC, RV, DLCO and a 6-minute walk, as they were reviewed. Imaging is reported as the chest X-ray or CT with the report impression preserved as written.
Does the plan keep sleep and pulmonary problems apart?
Yes. The plan is grouped by problem and numbered, so device settings, a pressure change, a titration study, mask and settings and driving advice sit under the sleep problem, while CT follow-up, an ABG, complete pulmonary function testing and tobacco cessation sit under the pulmonary one.
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 Pulmonology 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.