Appendix 2 Data Collection Template - High Dose Inhaled Corticosteroids in Adult Asthmatics Audit Number of patients and Audit Practice ………………… reviewed…………Audit carried out between …/…/2014 …/…/2014 lead ……………………… Patient Medication Indication Asthma Inhaler Step Any side Number of Number Are LABA More than If patient Action ID details for ICS review in technique down effects ICS inhalers of SABA and ICS 2 courses on step 4 Required inhaler in the last check attempted reported (e.g. (include inhalers inhaler of or 5 of patient 12 documented? in the symptoms of ICS/LABA issued in prescribed systemic BTS, have notes? months Yes or No past 3 adrenal combinations) past 12 separately? steroids they been months? suppression, issued in past months? Yes or No (oral or iv) referred to low bone 12 months? in previous a specialist mineral 12 asthma density, months? service? glaucoma, Yes or No Yes or No diabetes) ICS Dose Yes No Yes No Yes No Yes No Yes No Yes No Yes No inhaler
Appendix 2 Data Collection Template - High Dose Inhaled Corticosteroids in Adult Asthmatics Audit Practice ………………… Number of patients reviewed…………Audit carried out between …/…/2014 and …/…/2014 Audit lead ……………………… Patient ID Medication details Indication for ICS inhaler in patient notes? Asthma review in the last 12 months Inhaler technique check documented? Yes or No Step down attempted in the past 3 months? Any side effects reported (e.g. symptoms of adrenal suppression, low bone mineral density, glaucoma, diabetes) Number of ICS inhalers (include ICS/LABA combinations) issued in past 12 months? Number of SABA inhalers issued in past 12 months? Are LABA and ICS inhaler prescribed separately? Yes or No More than 2 courses of systemic steroids (oral or iv) in previous 12 months? Yes or No If patient on step 4 or 5 of BTS, have they been referred to a specialist asthma service? Yes or No Action Required ICS inhaler Dose Yes No Yes No Yes No Yes No Yes No Yes No Yes No
2_ReviewHighDoseICS_InAsthmaPatientsVer3.docx