|Name of Patient:
|Patient medication sensitivities/allergies:
|Patient identification e.g. ID number, date of birth:
|Pharmacist independent/supplementary prescriber(s)
|Condition(s) to be treated
|Aim of treatment
Control of Asthma symptoms, prevention of exacerbations and achievement of best possible pulmonary function, with minimal side effects.
|Summary of the case based on history taking and relevant investigations
Insert history taken in here. For asthma think about the following.
Presenting symptoms on the day. Asthma control test. Inhaler technique. Family history. Triggers. Peak flow readings (diary readings over several weeks if possible). Hospitalisations recently, Oral steroid use recently. Short acting beta agonist usage
Inhaled short acting β2 agonists
Long acting Beta agonist
Leukotreine receptor antagonist
Relief of asthma symptoms at step 1 and above
Prevention of asthma symptoms at step 2 and above
Prevention of asthma symptoms at step 3
| Dose schedule
As detailed in:
· BNF section 3
· BTS/SIGN 141 guideline
|Specific indications for referral back to the IP
Diagnosis in doubt after history taking or through spirometry.
Failure to respond to treatment at step 3.
Alarm symptoms or acute exacerbation
|Guidelines or protocols supporting Clinical Management Plan:
SIGN 141 for the management of asthma. Referring specifically to the care of adults in this case.
|Frequency of review and monitoring by:
Monthly until control is achieved.
As indicated by response to treatment above, but no less than 6 monthly
|Frequency of regular review by independent prescriber
|Process for reporting suspected or known adverse drug reactions
Record all interventions and consultations in a timely manner in the patient records via remote access if appropriate.
Notify by yellow card System if indicated.
|Shared record to be used by SP/IP:
Access to the electronic record in the surgery.
Credit for this management plan to the team at Robert Gordon University in Aberdeen. This was one of a few templates they offered as part of my IP course a few years ago. This was my favourite.
I should say that as I am still reasonably new to the IP role I have chosen initially to practise as a supplementary prescriber and more recently work up to practising as a fully fledged IP. I think this prudent approach involving reflection allows a future IP to carefully and explicitly lay out where their areas of competence lie.
I hope you find it useful.