How should I document a patient‑specific written asthma action plan with colour‑coded zones, controller and rescue medications (including generic names), peak‑flow or symptom reference ranges, triggers, inhaler technique, follow‑up instructions, and clinician/patient signatures?

How to Document an Asthma Action Plan

Every patient with asthma must receive a written asthma action plan that includes colour-coded zones (green, yellow, red), specific medications with doses, peak flow or symptom thresholds, and both patient and clinician signatures. 1

Essential Components to Document

Patient Identification and Baseline Information

• Document patient name, date of birth, emergency contact information, and date the plan was created 2
• Record the patient's personal best peak expiratory flow (PEF) value if using peak flow monitoring—this becomes the reference point for all zone calculations 2, 3
• Include the patient's baseline lung function (FEV1 or PEF ≥80% predicted when well-controlled) 2, 1

Green Zone: "Doing Well" (80-100% of Personal Best PEF)

Document the following in this section:

• Daily controller medications with generic names, specific doses, frequency, and delivery device 2, 1:

  • Example: "Fluticasone propionate 250 mcg, 2 puffs twice daily via metered-dose inhaler with spacer"
  • Include all long-term control medications such as inhaled corticosteroids, combination ICS-LABA, or leukotriene modifiers 1, 3

• Quick-relief medication for breakthrough symptoms 2, 1:

  • Example: "Albuterol 90 mcg, 2 puffs every 4-6 hours as needed for symptoms"
  • Specify that use should be ≤2 days per week when well-controlled 1

• Symptom criteria: No cough, wheeze, chest tightness, or shortness of breath; can do usual activities; no nighttime awakenings 2

• Peak flow range: Document specific numbers (e.g., "480-600 L/min" if personal best is 600) 2

Yellow Zone: "Getting Worse" (50-79% of Personal Best PEF)

Document clear escalation instructions:

• Symptom triggers for this zone: Cough, wheeze, chest tightness, shortness of breath, nighttime awakenings, or reduced ability to perform usual activities 2

• Peak flow range: Calculate and write specific numbers (e.g., "300-479 L/min" if personal best is 600) 2

• Medication adjustments with exact instructions 2, 1:

  • "Continue quick-relief medicine every 4 hours as needed"
  • For patients on ICS-formoterol: "Increase to [specific dose] every 4 hours"
  • Specify when to add or increase controller medication doses

• Time frame for reassessment: "Call provider if not improving in ___ days" (typically 24-48 hours) 2

Red Zone: "Medical Alert" (<50% of Personal Best PEF)

Document emergency instructions:

• Danger symptoms: Very short of breath, quick-relief medicines not helping, cannot do usual activities, symptoms same or worse after 24 hours 2

• Peak flow threshold: Document specific number (e.g., "less than 300 L/min") 2

• Emergency actions 2:

  • "Take [specific dose] of quick-relief medication immediately"
  • "Take prednisolone 30-60 mg orally" (document exact dose and number of tablets)
  • "Call 911 or go to emergency department immediately if trouble walking/talking due to shortness of breath or if lips/fingernails are gray or blue"

Trigger Identification and Avoidance

• List patient-specific triggers based on history and allergy testing results 2, 1, 3:

  • Environmental: tobacco smoke, specific allergens (dust mite, cockroach, pet dander, mold)
  • Irritants: strong odors, cold air, exercise
  • Medications: aspirin or NSAIDs if sensitive

• Document specific avoidance strategies tailored to identified triggers 2, 3

Inhaler Technique Documentation

• Document that proper inhaler technique was demonstrated and verified at the visit when the plan was created 1, 3
• Note the type of delivery device for each medication (MDI with spacer, dry powder inhaler, nebulizer) 2
• Include a reminder to bring all inhalers to every appointment for technique review 2

Follow-up Instructions

• Specify the next scheduled appointment date (every 2-6 weeks when initiating therapy or stepping up treatment; every 1-6 months once control is achieved) 1, 4
• Document criteria for unscheduled contact: worsening symptoms despite yellow zone treatment, increasing rescue medication use, or any red zone symptoms 2

Signatures and Acknowledgment

• Include signature lines for both the clinician and patient (or parent/guardian for children) 1
• Document that the plan was reviewed with the patient, questions were answered, and the patient demonstrates understanding of how to use it 2, 1

Critical Documentation Pitfalls to Avoid

Do not use vague instructions like "use inhaler as needed"—always specify exact doses, number of puffs, and frequency 2, 5. The most common error is failing to distinguish between controller medications (taken daily regardless of symptoms) and quick-relief medications (used for acute symptoms), which must be explicitly clarified in writing 2, 3.

Do not provide peak flow ranges as percentages only—calculate and document the actual numerical values in L/min based on the patient's personal best, as patients struggle with percentage calculations during acute episodes 2, 5.

Avoid generic action plans—the plan must be individualized with the patient's actual medications, doses, and personal best peak flow values to be effective 1, 5. Pre-printed templates are acceptable only if all patient-specific information is filled in completely.

Integration with Patient Education

The written action plan should be developed collaboratively during a face-to-face discussion where you teach the patient in simple language what asthma is, the difference between the two types of medications, and how to self-assess control 2, 1. Use the plan as a teaching tool, not just a handout—have the patient explain back to you what they would do in each zone to verify comprehension 2, 3.

Update the action plan at every follow-up visit as asthma control changes and treatment is adjusted 1, 3. The plan is a living document that evolves with the patient's disease course, not a one-time form.