Asthma Follow-Up Visit Note Template for Allergy Practices (ACT, Spirometry, FeNO and the Treatment Step)

The short answer: an asthma follow-up note needs five things. It

needs symptom control as a score, usually the Asthma Control Test

(ACT), recorded the same way every visit. It needs **exacerbations since

the last visit**, kept separate from day-to-day symptoms. It records

lung function, and FeNO if you measure it, next to the previous

values. It names the allergic triggers and exposures that matter for

this patient. And it ends with the treatment step: what the patient

takes now, how they actually take it, and the reason for any change.

Asthma follow-ups are easy to document badly, because a patient on a good

month says "fine" and a short note looks complete. The trouble shows up

later, when someone has to decide whether to step up, step down or add a

biologic and can't tell from the chart how controlled the patient really

was. Symptom control and exacerbation history are different questions.

As one review of the GINA approach puts it, "It is important also to ask

about risk factors for exacerbations, particularly previous

exacerbations" (Skolnik N, MDedge, March 2024). The template keeps them

apart.

This is a documentation aid, not a treatment protocol. Your practice's own

approach, and current guidelines, come first.

Template 1: symptom control

```

ASTHMA CONTROL (last 4 weeks)

Asthma Control Test (ACT), age 12+

• Score today: [ ] / 25
• Previous ACT: [ ] on [date]
• Change: [ ] points

or GINA symptom control questions (yes / no)

• Daytime symptoms more than twice a week: [ ]
• Any night waking due to asthma: [ ]
• Reliever needed more than twice a week: [ ]
• Any activity limitation due to asthma: [ ]
• Number of "yes" answers: [0 / 1-2 / 3-4]

Reliever use

• Reliever: [drug]; puffs per week, typical: [ ]
• Used before exercise only: [yes / no]

Patient's own words: [one line]

```

Pick one tool and keep using it, so the scores can be compared. The ACT

is "a patient self-administered tool for identifying those with poorly

controlled asthma", with "5 items, with 4-week recall (on symptoms and

daily functioning)". Scores "range from 5 (poor control of asthma) to 25

(complete control of asthma)", and "an ACT score >19 indicates

well-controlled asthma" (American Thoracic Society, ACT summary, citing

Nathan RA, et al. J Allergy Clin Immunol 2004;113:59-65). The minimally

important difference is "3 points between two groups or for changes over

time" (Schatz M, et al. J Allergy Clin Immunol 2009;124:719-23). That's

why the template asks for the change, not only today's number.

The GINA questions are quicker to ask in the room. "Well-controlled asthma

is defined as a negative response to all four of these questions, partly

controlled asthma is one or two 'yes' answers, and uncontrolled asthma is

three to four positive responses" (Skolnik, MDedge). Write the answers

down, not only the category, so the next clinician can see which one

changed.

Template 2: exacerbations and risk

```

EXACERBATIONS SINCE LAST VISIT ([date])

• Oral corticosteroid courses: [none / number, dates]
• Urgent care or ED visits for asthma: [none / dates]
• Hospital admissions: [none / dates; ICU or intubation ever: yes / no]
• Triggered by: [viral illness / allergen exposure / exercise / smoke /

other / unknown]

• Missed work or school: [days]

Other things to record

• Smoking or vaping, and smoke exposure at home: [ ]
• Comorbidities reviewed: [rhinitis / sinus disease / reflux /

obesity / sleep apnea / anxiety / other: ]

```

Count courses of oral steroids and visits by date, rather than writing

"a few flares". A dated list is what a payer asks for if the patient later

needs a biologic, and it's what the next visit compares against.

Template 3: lung function, FeNO and triggers

```

OBJECTIVE

Spirometry (today / most recent)

• FEV1: [ ] L, [ ] % predicted; FVC: [ ] L; FEV1/FVC: [ ]
• Bronchodilator response, if tested: [ ]
• Previous FEV1: [ ] on [date]
• Not done today, and why: [ ]

FeNO (if measured)

• Today: [ ] ppb; previous: [ ] ppb on [date]
• Read alongside: [symptoms / spirometry / adherence check]

Exam

• Wheeze today: [yes / no]; nasal exam: [ ]

ALLERGIC TRIGGERS AND EXPOSURES

• Sensitization on record: [allergens, test type and date]
• Exposure at home / work / school: [ ]
• Mitigation discussed: [none / specific steps]
• Allergen immunotherapy: [not on / SCIT: extract and phase]

```

FeNO is useful, but it isn't a control score on its own. The 2020 NAEPP

focused update, published in the *Journal of Allergy and Clinical

Immunology*, put it plainly: "It is not recommended to use FeNO as the

only measurement for asthma control" (AAAAI news release, December 3,

2020). A pediatric summary of the same update adds that "FeNO testing

should not be used alone to diagnose or manage asthma" (Cloutier MM, et

al. Pediatrics 2021). So the template asks what the FeNO was read

alongside.

The trigger section is where an allergy practice's note differs from a

primary care note. The same update says "allergen mitigation

interventions are not recommended for individuals with asthma who lack

sensitization" (AAAAI). That's why the note records the sensitization,

the test and its date, not only "dust mite precautions". For patients on

subcutaneous immunotherapy, the injection details belong in their own

note; the

immunotherapy visit note template

covers that. The 2020 update conditionally recommends immunotherapy as an

adjunct for patients with mild to moderate allergic asthma, and its

evidence review "did not support using sublingual immunotherapy to treat

allergic asthma" (Elward KS. Am Fam Physician 2021;104:446-447).

Template 4: treatment step and plan

```

TREATMENT

Current regimen

• Controller: [drug, strength], [puffs], [times daily]; since: [date]
• Reliever: [drug]; or ICS-formoterol used as both: [yes / no]
• Add-on: [none / LABA / LAMA / LTRA / other]
• Biologic: [none / drug, dose, start date, number of doses so far]
• Spacer: [yes / no]

Before any step-up, checked

• Adherence: [ ] (e.g. refill history, patient report)
• Inhaler technique: [observed today: correct / corrected]
• Triggers and exposures: [ ]
• Comorbidities: [ ]

Assessment

• Asthma, [severity], [well / partly / not] controlled

(ACT [ ] or GINA [ ] of 4; exacerbations since last visit: [ ])

• Change since last visit: [better / same / worse]

Plan

• Treatment change: [none / step up / step down / add: details]
• Reason: [one line, tied to the scores and exacerbations]
• Asthma action plan: [reviewed / updated / given]
• Follow-up: [weeks]; spirometry or FeNO next visit: [yes / no]

CODES (for clinician review)

• [e.g. J45.40 Moderate persistent asthma, uncomplicated /

J45.41 with (acute) exacerbation / J82.83 Eosinophilic asthma]

```

The "checked before any step-up" block is worth keeping even when the

answer is routine. A summary of the 2020 update advises checking

medication adherence, inhaler technique, environmental triggers and

comorbid conditions before stepping up therapy (Cloutier, Pediatrics).

A note that shows those were checked makes a step-up easy to follow

later.

Write the regimen the way the patient actually takes it. The 2020 update

made single maintenance and reliever therapy (SMART) with ICS-formoterol a

preferred option for many patients with moderate to severe persistent

asthma, with age ranges set out in the guideline (Elward, AFP). That

makes a separate "used as both" line useful: on SMART, more reliever puffs

can mean something different than on a separate rescue inhaler.

Write the reason for any change in terms of the scores ("ACT 15, down from

21; two prednisone courses since June") rather than "not controlled". For

coding, the

allergy ICD-10 coding guide

covers the J45 severity codes and eosinophilic asthma (J82.83). The

severity and whether the patient is exacerbating today both change the

code, so the assessment line should state both.

Where Medora fits

Medora is an AI copilot built only for allergy and immunology practices,

built with a working allergy practice, Allergy Affiliates in Bradenton,

Florida.

• Medora Copilot listens to the visit and drafts an allergy-structured

SOAP note, including pertinent negatives. It has visit templates built

for allergy, including asthma, follow-up and immunotherapy visits.

• Each assessment item in the note carries its suggested ICD-10 code, for

the clinician to review. It also drafts patient instructions from the

visit.

• Evidence Mapping links lines in the history and review of systems

back to the moment in the visit where they were said. So when the note

says "no night waking", the clinician can check where that came from

before signing.

• At a follow-up, Patient Intelligence shows a snapshot of the prior

visit, and chronic conditions are carried forward so they don't have to

be re-entered.

• The clinician reviews, edits and signs every note. Medora doesn't score

the ACT for the patient, and it doesn't decide the treatment step. Those

stay with the clinician.

In a 60-day pilot at Allergy Affiliates, the time an allergist spends

signing off each skin-test visit dropped sharply

(the case study).

Frequently asked questions

What should an asthma follow-up note include?

A symptom control score (ACT or the GINA questions) with the previous

score, exacerbations since the last visit with dates, lung function and

FeNO if measured, the relevant allergic triggers, the current regimen as

the patient actually takes it, and the plan with the reason for any

change. Adherence and inhaler technique should be documented before any

step-up.

What ACT score means well-controlled asthma?

The ACT has five questions about the last four weeks, scored from 5 to 25.

A score above 19 indicates well-controlled asthma. A change of 3 points is

the minimally important difference.

Can FeNO alone show whether asthma is controlled?

No. The 2020 NAEPP focused update recommends against using FeNO as the

only measurement of asthma control. Record it alongside symptoms, lung

function and an adherence check.

Should the note record allergen sensitization for asthma patients?

Yes. The 2020 update does not recommend allergen mitigation for patients

with asthma who lack sensitization, so the sensitization, the test and

its date belong in the note next to any mitigation advice.

Who makes the treatment call when Medora drafts the note?

The clinician. Medora Copilot drafts the visit note for the clinician to

review, edit and sign, and the clinician makes every treatment change.

Try it on your own visits

• See how Medora handles allergy documentation
• Start the 14-day free trial of Medora Scribe (no card needed)
• Book a demo
• Read the full buyer's guide
• The allergy immunotherapy visit note template
• The allergy ICD-10 coding guide

*Sources: American Thoracic Society, Asthma Control Test (ACT) summary,

SRN Assembly questionnaires, citing Nathan RA, Sorkness CA, Kosinski M, et

al. Development of the asthma control test: a survey for assessing asthma

control. J Allergy Clin Immunol. 2004;113:59-65, and Schatz M, Kosinski M,

Yarlas AS, et al. The minimally important difference of the Asthma Control

Test. J Allergy Clin Immunol. 2009;124:719-23. Skolnik N. What's changed

in asthma treatment? Quite a bit. MDedge, March 12, 2024. AAAAI news

release, New asthma guidelines published in The Journal of Allergy and

Clinical Immunology, December 3, 2020. Cloutier MM, Teach SJ, Lemanske RF

Jr, Blake KV. The 2020 focused updates to the NIH asthma management

guidelines: key points for pediatricians. Pediatrics.

2021;147(6):e2021050286. Elward KS. Asthma management guidelines: focused

updates for 2020. Am Fam Physician. 2021;104(5):446-447. Quotes are from

these sources. Check the full guidelines and prescribing information, and

follow your own protocols.*