Departments of 1Medicine and 2Family Medicine & Public Health, Sultan Qaboos University Hospital, Muscat, Oman; 3Department 
of Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
*Corresponding Author email: orawas@squ.edu.om

SQU Med J, December 2010, Vol. 10, Iss. 3, pp. 335-340, Epub. 14th Nov 10 
Submitted 3rd April 10
Revision ReQ. 30th June 10, Revision recd. 9th July 10
Accepted 21st July 10

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 


 2009 31 2008 1
 14

 42 100
 57% 25% 2%
 5% 3% 48% 9% 19%
 77%
 24% 3%
 11%23% 37%






aBstract: Objectives: Asthma exacerbation is a major cause of morbidity and it is usually an indication of poor 
control. Appropriate management and documentation of the clinical assessment of an exacerbation, its severity, 
contributing factors and treatment are all essential components of asthma control. The aim of this study was 
to assess the documentation of the management of asthma exacerbations by primary care physicians (PCPs). 
Methods: A retrospective analysis was carried out on patient records from 1 May 2008 to 31 April 2009. We included 
all acute exacerbation episodes in asthmatic patients aged ≥ 14, who received nebulized bronchodilators in the 
two family medicine clinics attached to Sultan Qaboos University Hospital (SQUH), Oman. A special form was 
designed to collect PCP's documented management. Results: A total of 67 patients with 100 episodes were treated 
by 42 PCPs. Documentation of clinical assessment was low for previous admissions (2%), rescue nebulization 
(25%), duration of symptoms (57%), trigger factors (19%), compliance (9%), clinical signs (48%), peak flow rate  
(3%), and inhaler technique (5%). The diagnosis of asthma exacerbation was documented in 77% of the episodes. 
Documentation of therapy was also low (3% for oxygen therapy and 24% for systemic steroids). Documentation 
of post-nebulization assessment, follow-up appointment, and referral to asthma clinic were found in 37%, 23% 
and 11% of cases respectively. No documented evidence was found for referral to chest specialist or spirometry. 
Conclusion: Our study indicates major deficiencies in the documentation of asthma exacerbation management 
among PCPs. Further research is needed to identify the causes of those deficiencies. Following the standardised 
management protocol can be helpful.

Keywords: Management; Asthma Exacerbation; Primary care; Guidelines; Documentation; Oman

CLINICAL & BASIC RESEARCHCLINICAL & BASIC RESEARCH

Documentation of the 
Management of Asthma Exacerbation in 

Adults by Primary Health Care Physicians in a 
Teaching Hospital in Oman

 Sawsan A Baddar,1 Aida I Al-Ismaili,2 Muna A Al-Taie,2 Abdulaziz M Al-Mahrezi,2 *Omar A Al-Rawas3 



Documentation of the Management of Asthma Exacerbation in Adults  
by Primary Health Care Physicians in a Teaching Hospital in Oman

336 | SQU Medical Journal, December 2010, Volume 10, Issue 3

Asthma is a chronic disease which requires regular follow-up for monitoring of disease activity and the necessary 
adjustment of pharmacological treatment. Asthma 
exacerbation is a major cause of morbidity and 
reflects poor asthma control.1 The assessment of 
severity, identification of contributing factors and  
the review of therapy are not only the main 
components of asthma exacerbation management, 
but are also essential for long term asthma control.2

Despite advances in asthma management and 
the widespread use of evidence-based asthma 
management guidelines, there are worldwide 
concerns that many asthma patients receive 
inadequate care.1 Due to time limitation or busy 
clinics, the unfamiliarity of general practitioners 
with the guideline components, multiple providers 
and the lack of standardised management  protocols, 
most of the time patients are treated for the existing 
acute symptoms, and long term management issues 
are often forgotten, missed or neglected.1-4

Our previous studies indicated that 
asthma is common in Omani school children 
and is often associated with relatively severe  
symptoms.5-8 Although there is no information on 
the burden of asthma in Omani adults, our clinical 
experience suggests that asthma is also common 
in adults and may be under-treated. In a previous 
study, we found asthma care providers have poor 
inhaler techniques.9 We also demonstrated poor 
documentation of asthma management in a tertiary 
hospital outpatient setting despite availability 
of a documentation protocol.10 Furthermore, an 
earlier survey, conducted in 1997 among general 
practitioners practising in private practice in 
Oman, revealed that the treatment of stable and 
acute asthma was not in line with international 
guidelines.11

The aim of the present study was to assess the 
documentation of primary care physicians in the 

management of asthma exacerbation by reviewing 
the patient’s electronic medical records in the two 
family medicine clinics attached to Sultan Qaboos 
University Hospital.

Methods 
Sultan Qaboos University, Oman, has on its campus 
one teaching hospital, Sultan Qaboos University 
Hospital, (SQUH) and two family medicine 
clinics (FMCs): the Students Clinic and the Staff 
Clinic. SQUH has a fully equipped Pulmonary 
Function Tests Laboratory (PFTL) which serves 
the hospital and the two FMCs. Each FMC has its 
own pharmacy in addition to access to the SQUH 
main pharmacy. All the necessary medications for 
the management of asthma are available in SQU 
pharmacies including: intravenous hydrocortisone; 
oral corticosteroids; inhaled corticosteroids (ICs) 
in three different devices; inhaled long acting ß2 
agonists (LABA) in two different devices; combined 
medication in two different devices; inhaled short 
ß2 agonists (salbutamol in two different devices); 
and nebulized bronchodilators (salbutamol and 
ipratropium bromide solutions). Both clinics have 
peak flow meters with disposable mouthpieces, 
oxygen therapy, and pulse oxymeters. The two 
clinics are run by medical officers (MOs) and 
family medicine residents (Residents) under the 
supervision of senior family medicine physicians. 
Medical care is free for all Omanis and there is 
no restriction on the primary care physicians 
prescribing any of the available asthma medications, 
or referring the patient to the SQUH pulmonary 
clinic or the PFTL.

A retrospective analysis of patient records was 
carried out for the 12 month period 1 May 2008 
to 31 April 2009. It included all episodes of asthma 
exacerbation in patients aged 14 years or more, 
who received nebulized bronchodilator therapy 

Advances in Knowledge
1. This is the first study in Oman to look into the documentation of the management of acute exacerbation of asthma and the compliance 

of primary health care physicians with the Oman National Asthma Management Guidelines.
2. The study has identified important deficiencies in the documentation of essential elements of asthma management by primary health 

care physicians.
Application to Patient Care
1. The study has identified areas for improvement in the management of asthma exacerbation.
2. The study has highlighted the importance of documentation in the medical records for the management and follow-up of asthma 

patients.



 Sawsan A Baddar, Aida I Al-Ismaili, Muna A Al-Taie, Abdulaziz M Al-Mahrezi and Omar A Al-Rawas

Clinical and Basic Research | 337

(salbutamol with or without ipratropium bromide) 
and had a diagnosis of asthma documented in 
their electronic medical records. Episodes treated 
by the investigators were excluded from the study. 
Since repeated nebulization for the same episode 
are directly given by the nurse without routine re-
assessment by the physician, they were excluded 
from the analysis. Patients with other diagnoses 
were also excluded from analysis. The data were 
extracted from physician’s documentation in 
clinical notes, prescribed medication, nursing 
notes and summary management sections of the 
Hospital Information System (HIS) (InterSystems 
Trakcare™, Version W650, 2001-2005, Cambridge, 
Massachusetts) using a specifically designed form 

derived from our asthma management protocol.10 

Statistical analysis was performed with using the 
Statistical Package for the Social Sciences software 
(SPSS), Version 10, (SPSS, Chicago, Illinois). 
Comparisons between groups were done using the 
chi-square test. A P value of <0.05 was considered 
statistically significant. The study was approved by 
the Medical Research & Ethics Committee of the 
College of Medicine & Health Sciences at Sultan 
Qaboos University.  

Results
A total of 67 patients (39 male) with 100 asthma 
exacerbation episodes met the criteria and were 
included in this analysis. Fifty-one episodes were 
managed in the Staff Clinic and 49 episodes in the 
Students Clinic. These episodes were managed by 42 
Primary Care Physicians (PCPs) (17 medical officers 
and 25 residents), and 51% of the episodes were 
managed by more than one physician. Nebulized 
bronchodilator therapy consisted of salbutamol 
alone in 68% of the episodes and combination 
therapy (salbutamol and ipratropium bromide) in 
32%.

Table 1 compares the documentation for asthma 
exacerbation management by the medical officers 
and residents. Documentation of clinical assessment 
was low for previous admissions (2%), rescue 
nebulization (25%), duration of symptoms (57%), 
trigger factors (19%), compliance (9%), clinical signs 
(48%), peak flow rate (3%), and inhaler technique 
(5%). The diagnosis of asthma exacerbation was 
documented in 77% of the episodes. There was no 
significant difference between the two physician 
groups in the documentation in any of the items 
except for the duration of symptoms which was 
documented more frequently by residents (64%) 
compared to  medical officers (35% P = 0.02).

Table 2 shows the percentages of episodes 
with physicians’ documentation of the standard 
components of asthma exacerbation management. 
Documentation of therapy was low (3% for oxygen 
therapy and 24% for systemic steroids). Most of the 
episodes (73%) had no documentation for post-
nebulization assessment. ICs therapy was prescribed 
in 58% of the episodes. Cough preparations and 
antibiotics were prescribed in 37% and 10% of the 
episodes respectively. Documentation for follow-up 
appointments was present in 23%. Referral to the 

Table 1: The number (n) and percentage (%) of episodes 
with documentation of the essential elements of clinical 
assessment of asthma exacerbation

   Episodes by physician category

All 
Episodes
(N = 100 

episodes)
(%)

 Medical  
Officers
(n = 23 

episodes)
 (%)

Residents
(n = 77 

episodes)
(%)

Symptoms 81 17 (74) 64 (83)

Symptoms 
duration

57 8 (35) #49 (64)

Trigger 
factors

19 4 ( 17) 15 (19)

Family 
history

29 6 (26) 23 (30)

Medication 
history

30 7 (31) 23 (30)

Nebulization 
history

25 5 (21) 20 (26)

Admission 
history 

2 0 2 (3)

History of 
atopy

13 2 (9) 11 (14)

Smoking 
history

8 2 (9) 6 (8)

Compliance 7 0 7(10)

Clinical 
signs

48 8 (35) 40 (52)

Inhaler 
technique

5 0 5 (6)

Actual peak 
expiratory 
flow rate

3 0 3 (4)

Diagnosis 77 19 (83) 58 (75)

Note: # = P = 0.02



Documentation of the Management of Asthma Exacerbation in Adults  
by Primary Health Care Physicians in a Teaching Hospital in Oman

338 | SQU Medical Journal, December 2010, Volume 10, Issue 3

asthma counselling clinic was evident in 11%, but 
there was no documented evidence of referral to a 
chest specialist or for spirometry.

A review of the records of the 67 patients 
revealed that 19 (28%) of patients had had more 
than one asthma exacerbation during the previous 
year. Although 32 (48%) of patients had documented 
evidence of maintenance ICs treatment, only 22 
(33%) had ICs prescribed during the three months 
prior to the current exacerbation. Documentation 
of compliance and assessment of inhaler technique 
was present in only (3.5%) of patients who received 
inhaled medication.

Discussion
Acute asthma exacerbations reflect poor asthma 
control and are strong independent predictors of 
future exacerbations.2 Documentation of clinical 
assessment and treatment is not only important 
for assessing quality of care, but also for follow-
up and communication with other health care 
providers who may also participate in the care of 
the same patient.12 International asthma guidelines 
recommend assessment and documentation of 
symptoms and signs to ascertain control. This in turn 
helps in optimising therapy.13,14 This study revealed 
significant deficiencies in the documentation of 

the clinical assessment and management steps for 
acute asthma exacerbation in a setting of university 
primary health care clinics, with no significant 
difference between medical officers and residents. 
The findings of this study have major implications 
for the quality of asthma care not only in our setting, 
but also in the community at large as the majority 
of Omani primary care physicians are trained in 
SQUH and its affiliated health care centres.

A history of previous admission for asthma 
exacerbation, especially to an intensive care unit, is 
an index of poorly controlled severe asthma and is 
considered essential information in the evaluation 
of asthma especially during exacerbation.15 

Montealegre et al., found that the documentation 
of previous admission to an emergency room and 
intensive care unit was present in only 3.5% of the 
records.15 In our study, a previous record of acute 
exacerbation was present in 25% of the episodes, but 
a history of admission for asthma was documented 
in only 2%.

The intensity of asthma exacerbations may 
vary from mild to life-threatening.16 Asthma  
exacerbations are associated with airways 
obstruction that should be objectively quantified by 
peak expiratory flow rate (PEFR) or forced expiratory 
volume in one second (FEV1) measurement.14 
In this study, actual PEFR was documented in 
only 3% of the episodes with no documentation 
for percentage predicted values. In our previous 
study, where we used a standardised management 
protocol supported by a special form to document 
all aspects of asthma management during follow-
up, the documentation of actual and percentage 
predicted PEFR was present in 100% and 88% of the 
records of patients seen by primary care physicians 
at the same primary care clinic.10

Asthma is a variable disease, and various 
factors can lead to an increase (or decrease) in 
asthma symptoms and the level of asthma control. 
Documenting asthma variability and assessing 
both adherence and possible triggers over time 
may allow patients and physicians to develop 
treatment plans that anticipate, rather than follow, 
changes in the level of asthma symtoms.17 In our 
study, the documentation of these elements was 
very poor. For example, the documentation of a 
history of atopy, smoking and trigger factors was 
present in only 13%, 3% and 18% of the episodes 
respectively. The documentation of compliance and 

Table 2: The number and percentage of various 
therapeutic interventions documented for the 
management of asthma exacerbations

                                      Episodes by physician category

All 
Episodes
(n = 100 

episodes)
%

 Medical 
Officers
(n = 23 

episodes)
(%)

Residents
(n = 77 

episodes)
 (%)

Systemic 
steroids

24 5 (22) 19 (25)

Inhaled 
Corticosteroids

58 15 (62) 43 (56)

Long acting ß2 
agonist

23 8 (35) 15 (19)

Short acting ß2 
agonist

83 18 (78) 66 (86)

Oxygen 
therapy

3 1 (4) 2 (3)

Antibiotics 10 0 10 (13)

Cough 
preparations

37 10 (43) 27 (35)



 Sawsan A Baddar, Aida I Al-Ismaili, Muna A Al-Taie, Abdulaziz M Al-Mahrezi and Omar A Al-Rawas

Clinical and Basic Research | 339

inhaler technique was also very low (5% and 9% 
respectively).

The low documentation of clinical assessment 
and treatment observed in our study is consistent 
with findings in others studies.18-21 In a study of 
100 consecutive children from Kuwait admitted 
with acute asthma exacerbation,19 there was no 
documentation of severity in 63%, with poor 
documentation of most aspects of management 
including lack of post-discharge planning. Similarly, 
Arnold et al.20 found that only 47% of admitted 
asthmatic patients were receiving ICs prior to 
admission and, upon discharge, 25% of patients 
did not receive ICs for maintenance therapy. Like 
previous reports,19,21 improper use of medications 
such as antibiotics and cough suppressants for 
acute exacerbations of asthma appears to be 
common in our primary care clinics (prescribed in 
approximately 40% of the episodes).

In an institution where multiple providers are 
involved in the management of the same patient, as is 
the case in our setting, adherence to guidelines may 
be difficult and the risk of poor documentation with 
omission of essential elements of the management 
could be high leading to poor or inadequate 
management. In these institutions, standardisation 
of care becomes even more essential. In a previous 
study, we found that introducing a standardised 
protocol, supported by a specifically designed 
documentation form, resulted in better adherence 
to asthma management guidelines by primary 
care physicians during asthma outpatients follow-
up.10 For example, the documentation of previous 
admission history was present in 95% of the records 
compared to only 2% in this study. Training of health 
care providers has also been shown to reinforce 
good practice.22

The present study has several limitations. Our 
objective was to assess PCPs’ compliance with the 
standard guidelines for the management of acute 
exacerbation by reviewing the documentation in 
the electronic medical records. We only analysed 
the documented information. We did not interview 
the physicians to assess their knowledge, attitude 
or actual practice during management of asthma 
exacerbations. We also did not assess their 
accuracy in using the peak flow meter or inhaler 
devices. It is possible that the physicians measured 
the peak flow rate and assessed the severity of 
asthma exacerbation, but did not document these 

actions. Similarly, some management plans and  
interventions might have been arranged and/
or executed without documentation. Therefore 
poor documentation may not directly translate 
to poor compliance with the guidelines of asthma 
exacerbation management. Senturia et al.23 
compared medical records to parents' interviews 
and found that the medical record was not an 
accurate measure of specific aspects of asthma  
care due to missing data. However, in our HIS 
(Trakcare) system some management steps 
can only be executed through specific orders 
(e.g. prescriptions, referrals, and follow-up 
appointments), and therefore the system does 
reflect a true record of these steps of management. 
In addition, since patient follow-up and monitoring 
can only be done through reference to previous 
documentations regarding their condition, proper 
documentation is an essential component of best 
clinical practice and is commonly used as an index 
of actual practice in retrospective studies.12,2

Conclusion 
Our study showed inadequate documentation in 
every aspect of clinical assessment and management 
of asthma exacerbation among primary care 
physicians. In our opinion, this is a major cause for 
concern and may indicate poor compliance with 
national and international guidelines for asthma 
management. Given the fact that the majority 
of Omani primary care physicians are trained 
in SQUH and its affiliated healthcare centres, 
it is imperative to evaluate the causes of such 
deficiencies carefully and ensure good compliance 
not only with documentation guidelines, but also 
with actual management guidelines. The use of 
a standardised management protocol supported 
by specifically designed forms could encourage 
physicians to adhere to guidelines and document 
their practice. Obstacles to best practice should be 
identified and addressed urgently. 

c o n f l i c t o f i n t e r e s t
The authors reported no conflict of interest.

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