Pulmonology Follow Up Maintenance

---
name: pulmonology-follow-up-maintenance
description: |
  Plan follow-up and maintenance so gains for patients with lung and breathing conditions are checked and sustained.
  TRIGGERS - Use when a pulmonologist needs a follow-up & maintenance schedule for patients with lung and breathing conditions in a respiratory ward and lung function laboratory.
category: Pulmonology
license: MIT
version: 1.0
---
# Follow-Up & Maintenance Schedule — Pulmonology

Plan follow-up and maintenance so gains for patients with lung and breathing conditions are checked and sustained. The deliverable is a follow-up schedule with intervals, checks and escalation triggers.
This skill is written for a pulmonologist working with patients with lung and breathing conditions in a respiratory ward and lung function laboratory.

## When to use
- You are a pulmonologist preparing, delivering or reviewing this part of your work in a respiratory ward and lung function laboratory.
- You need a defensible, repeatable approach that produces a follow-up schedule with intervals, checks and escalation triggers.
- A colleague, auditor or client asks how this was done and what evidence supports it.

## Key Concepts
| Term | Meaning |
|------|---------|
| Spirometry | a breathing test measuring how much and how fast air moves |
| Exacerbation | a sudden worsening of a chronic condition |
| Hypoxia | abnormally low oxygen levels in the body |

## Workflow
1. **Step 1** - Set follow-up intervals from the plan and from how spirometry quality rate is expected to move over time
2. **Step 2** - Define what is checked at each contact, using spirometers where measurement is needed, and record it in spirometry reports
3. **Step 3** - Give patients with lung and breathing conditions clear guidance for the interval: what to do, what to watch for, when to make contact sooner
4. **Step 4** - Act early on warning signs — deterioration linked to missed lung cancer signs shortens the interval, never lengthens it
5. **Step 5** - Close the follow-up cycle formally when goals are met, with a summary and re-entry route if needs return

## Profession-Specific Components
| Component | Details for Pulmonology |
|-----------|-------------------------------|
| Core documentation | spirometry reports; sleep study results; bronchoscopy reports; oxygen assessments |
| Core tools & equipment | spirometers; bronchoscopes; non-invasive ventilators; sleep study equipment |
| People involved | patients with lung and breathing conditions; the pulmonologist; colleagues and other services in a respiratory ward and lung function laboratory |
| Primary record | spirometry reports — keep it current, dated and attributable |

## Output Format
**Context:** [Situation in a respiratory ward and lung function laboratory] | **Objective:** [What this must achieve] | **Audience:** [patients with lung and breathing conditions and other stakeholders]

The finished output is a follow-up schedule with intervals, checks and escalation triggers, structured as:
1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

### Action Plan
1. **Immediate:** Confirm scope, consent and the evidence available in spirometry reports.
2. **Short-term:** Complete the workflow steps and record outcomes against spirometry quality rate.
3. **Medium-term:** Review results, close actions, and update local procedures in a respiratory ward and lung function laboratory.

## Success Metrics
| Metric | Target | Method |
|--------|--------|--------|
| spirometry quality rate | Agree a local target and track the trend | Measured from spirometry reports and reviewed on a set cycle |
| COPD exacerbation readmissions | Agree a local target and track the trend | Measured from spirometry reports and reviewed on a set cycle |
| oxygen assessment timeliness | Agree a local target and track the trend | Measured from spirometry reports and reviewed on a set cycle |
| clinic outcomes | Agree a local target and track the trend | Measured from spirometry reports and reviewed on a set cycle |

## Guardrails & Quality Checks
- Never let this happen: missed lung cancer signs.
- Never let this happen: ventilator-associated harm.
- Never let this happen: untreated sleep apnoea.
- Work only within the competence and authority of a pulmonologist; escalate or refer anything beyond it.
- Record facts and observations, not speculation, and keep records confidential to a respiratory ward and lung function laboratory's rules.
- Verify names, dates, figures and measurements twice before anything is issued or signed off.
- Use only real, verified information from the case in hand — never invent results, credentials or evidence.

## Example (illustrative)
A pulmonologist in a respiratory ward and lung function laboratory applies this workflow for patients with lung and breathing conditions: they open
spirometry reports, work through the five steps using spirometers, and close by recording
the outcome against spirometry quality rate and agreeing the next review date. (Illustrative example only —
replace with the real details of the case in hand.)