 
Health Care Provider
Healthcare providers, parents, schools, and community
agencies must work together in a collaborative
manner to improve asthma management.
Health Care Provider Toolbox
Asthma Action Plan
Asthma Action Plan- English
Asthma Action Plan- Spanish
Instructions for the Health Care Provider
This plan is designed to help children and families improve control of their asthma and provide instructions in the event of an exacerbation at school. The patient /family should be able to demonstrate that they understand how to use this plan, and the medications you have prescribed. This form has been designed for the primary care provider to use with families who need a relatively simple asthma management regimen. Once a family has become more informed about asthma, a plan can be developed with additional flexibility in treatment. Families should be given additional educational materials about asthma, peak flow monitoring, and environmental control.
When completing the plan: If any questions- get one completed!!! It might save a life...
Directions for the Provider
- Do not use medical abbreviations such as bid, PO or q4. Please use twice a day, by mouth or every 4 hours.
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Type or print clearly for all copies to be clear and understandable- this is a tool for your patients, families and schools.
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Check off the patient’s asthma severity level and triggers that may cause symptoms
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Sign the form and fill in your office phone and fax number
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Have the parent sign the asthma action plan.
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Give the White copy to the family/patient, the Yellow copy to the school/day care center and keep the Pink copy for your records. THE YELLOW COPY IS THE ONLY FORM THAT SHOULD BE PROVIDED TO THE SCHOOL!
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Since the Newly updated 2007 NHLBI ERP-3 Clinical guidelines indicate Peak Flow Meters as an option for use... we suggest assessing the patient & familie's ability and willingness to committ to this tool's use. The PFMs can be very helpful to some families... Asthma Action Plans now have versions with PFMs and without... The majority are submitted without PFM readings or inaccurate readings.
For PEAK FLOW METERS: Complete information for each zone as follows.
Green Zone: (80-100% -Pulmonary Function)
• Please list all controller medicines the patient takes on basis. How much and how often to take them. Identify reliever medicine the patient should use before PE/Sports/Exercise. Mark YES when you and the parent want their child to CARRY & USE medicine at school.
Yellow Zone: (50-79% -Pulmonary Function)
• Please add any reliever/rescue medications that should be taken. Instruct the patient to continue with green zone medicines. Include how long to continue taking these medicines and when to contact the provider.
Red Zone: (Under 50% -Pulmonary Function)
• Explain to the patient that these symptoms indicate an asthma emergency. List any medications to be taken while waiting to speak to the provider or preparing to go to the emergency room.
Peak flow readings are optional but do help school health care providers and parents to assess severity of symptoms and effectiveness of medication.
Other Tips & Facts to the use of Peak Flow Meters:
- The "Personal Best" peak flow should be determined when the child is symptom-free. A diary can be used to determine personal best, and usually are part of the peak flow meter package.
- A peak flow reading should be taken at all asthma visits (with the same meter consistently) and personal best should be reevaluated regularly (recommened every 6 months for a growing child). Because peak flow readings may vary with the meter used, instruct your patients to bring their peak flow meter to every visit.
- The RCAN Asthma Action Plans have recently been updated to meet the new NHLBI ERP-3 guidelines, with PFM and without readings... and to include more focus on symptom recognition as well as environmental triggers.
- Electronic Medical Records are a great new and trendy mechanism to facilitate AAP use... More and more offices are using them... Physicians & patients should be advocating to have these forms incorporated into EMR so that more patients have one at different health care settings and results can be shared. If you are interested in helping RCAN facilitate changes in EMR and the use of AAPs please contact us at (585) 442-4260.
Carry & Use "Inhaler Law"
New York State Consolidated Laws: Education
S 916. Pupils afflicted with asthma. The board of education or trustees of each school district and board of cooperative educational services shall allow pupils who have been diagnosed by a physician or other duly authorized health care provider with a severe asthmatic condition to carry and use a prescribed inhaler during the school day, with the written permission of a physician or other duly authorized health care provider, and parental consent, based on such physician's or provider’s determination that such pupil is subject to sudden asthmatic attacks severe enough to debilitate such pupil. A record of such permission shall be maintained in the school office.
Clinical Guidelines for the Treatment & Management of Asthma
The NAEPP Clinical Guidelines for the Treatment and Management of Asthma can be found at NHLBI under Asthma guidelines. The New York State Department of Health has produced a local version and a pocket guide to assist with use. A DVD Continuing Education Program has also been developed to faciliate how to apply the guidelines. Both items are free of charge and can be ordered through the NYS DOH Asthma website.
Certified Asthma Educators (AE-C):
The National Asthma Educator Certification Board (NAECB) developes, conducts and overssees the board certification for this credentialling. 3rd party review courses are available through similar missioned organizations. Contact your local coalition or theNAECB for more information.
Patient & Provider led Assessment of Asthma Control
The Rules of Two ®
is a great way to identify if you need to talk to your physician
about your child's Asthma Control
Three simple questions
1. Do you take your quick- relief inhaler more than TWO times per week?
YES NO
2. Do you awaken at night with asthma more than TWO times per month?
YES NO
3. Do you refill your quick-relief inhaler more than TWO times per year?YES NO
If you can answer YES to ANY of these questions
ask your Doctor about
"CONTROLLER MEDICINES"
These medications help
PREVENT ASTHMA ATTACKS!
Remember not to make any changes in your medicines unless ordered by your doctor....
The Asthma Control Test ™(ACT)
The ACT is a valided survey that has been included in the NHLBI NAEPP Clinical Guidelines as a recommended tool for use to assess overall asthma control. It is a short, 5 question self reported survey, developed by Quality Metric Incorporated in 2002. It is currently sponsored by the American Lung Association and Glaxo Smith Kline. Two forms include the adult form (for ages 12 and over) and a second non-validated version for under 12 yrs. Both are available in English & Spanish.
If an ACT score is 19 or less, there may be an indication that asthma is not under control.
If an ACT score is 20 or more, asthma seems to be well controlled, but should be discussed at the next appointment
ACT’s development follows a paradigm shift in the treatment of asthma, from a focus on asthma severity to asthma control. Specifically, ACT helps identify and detect asthma patients who are not well controlled. It was designed with input from asthma experts who helped establish cut-point scores to improve the clinical utility of the survey. |
