Medical Procedure Documentation: Asthma Well-Controlled Based on ACT, C-ACT, ACQ, or ATAQ Score and Results Documented (G9432)

Name of the Procedure:

Common Names: Asthma Control Assessment Technical/Medical Term: Asthma Well-Controlled Documentation Based on Standardized Scores

Summary

This procedure involves assessing and documenting the control level of a patient's asthma using standardized scoring systems. The assessment helps healthcare providers ensure that asthma is well-managed, reducing the risk of exacerbations and improving the patient’s quality of life.

Purpose

Asthma Control Assessment is used to measure how well asthma symptoms are managed over time. The primary goal is to document asthma as well-controlled to minimize symptoms, prevent asthma attacks, and improve overall respiratory health.

Indications

• Patients with a confirmed diagnosis of asthma.
• Individuals experiencing asthma symptoms such as shortness of breath, coughing, wheezing, or chest tightness.
• Regular follow-up in asthma management protocols.

Preparation

• No specific fasting or medication adjustments required.
• Patients might complete a questionnaire (ACT, C-ACT, ACQ, or ATAQ) either in the clinic or ahead of time.
• A baseline assessment involving a clinical evaluation.

Procedure Description

1. Assessment Tool Selection: Choose one of the standardized scoring tools (ACT, C-ACT, ACQ, or ATAQ) relevant to the patient’s age and condition.
2. Questionnaire Completion: The patient completes the selected questionnaire, providing information on recent asthma symptoms, frequency, and severity.
3. Scoring and Interpretation: Healthcare providers score the questionnaire.
4. Documentation: Results are documented in the patient’s medical record, identifying asthma as well-controlled if applicable.

Tools, Equipment, or Technology Used

• ACT (Asthma Control Test) Questionnaire
• C-ACT (Childhood Asthma Control Test) Questionnaire
• ACQ (Asthma Control Questionnaire)
• ATAQ (Asthma Therapy Assessment Questionnaire)

Anesthesia or Sedation

• Not applicable.

Duration

The procedure typically takes about 15 to 20 minutes, including patient completion of the questionnaire and clinician evaluation.

Setting

• Outpatient clinic
• Primary care office
• Specialized respiratory or allergy clinic

Personnel

• Primary care physicians
• Pulmonologists or asthma specialists
• Nurses or medical assistants

Risks and Complications

• Common: Minimal risk involved; some patients might feel stressed or anxious while assessing their condition.
• Rare: None identified since this is a non-invasive, questionnaire-based assessment.

Benefits

• Improved Asthma Management: Helps in tailoring treatment plans for better asthma control.
• Quality of Life: Reduces the risk of severe asthma attacks and improves daily life by managing symptoms effectively.
• Timely Intervention: Identifies poorly controlled asthma for timely medical intervention.

Recovery

• No recovery required.
• Patients can resume normal activities immediately after the assessment.

Alternatives

• Peak Flow Meter Use: Regular home-based monitoring of asthma control.
• Spirometry: Detailed lung function tests performed by specialists to assess control and adjust treatment as needed.

Pros and Cons of Alternatives

• Peak Flow Meter: Easy but less comprehensive.
• Spirometry: Detailed and diagnostic but requires specialized equipment and settings.

Patient Experience

• During the Procedure: Patients generally fill out a brief questionnaire, reporting their recent asthma symptoms and impacts.
• After the Procedure: They receive immediate feedback on their asthma control status, with any necessary adjustments to treatment discussed accordingly.

Pain Management and Comfort Measures

• Not applicable, as the procedure is painless and straightforward. Doctors and nurses ensure a comfortable environment for patients to discuss their symptoms openly.