Provider Info

Working Together to Control Asthma!

Healthcare providers, parents, schools, and community
agencies must work together in a collaborative
manner to improve asthma management.

Asthma Action Plan
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.
• Type or print clearly for all copies to be clear and understandable- this is a tool for your patients, families and schools.
• Check off the patient’s asthma severity level and triggers that may cause symptoms
• Sign the form and fill in your office phone and fax number
• Have the parent sign the asthma action plan.
• 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!
• 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.

Asthma Action Plan directions for the Provider
Ling to Asthma Action Plan E-FORM - English
Link to Asthma Action Plan E- FORM - Spanish
Link to RCAN environmental Home assessment sheet
Link to Rules of Two
Link to Asthma Control Test