Adverse Reaction/Incident Note (Essential Oil Exposure)

Date/Time: [Date and time of documentation, including time zone]

Encounter Type/Location: [clinic / ED / urgent care / telehealth] [Specific location or platform]

Author/Role: [Author name and credentials or role]

Source of History: [patient / caregiver / EMS / other] (Note reliability and limitations if applicable.)

Chief Complaint: [Chief complaint in patient's own words] (Quote when directly available.)

Event Summary

[Concise event overview] (Provide a 3–6 sentence summary that includes: suspected exposure with product name and route; key symptoms with any severity features; timeline from exposure through symptom onset to clinical evaluation; actions already taken such as decontamination, home treatment, or EMS involvement; current clinical status; and any escalation decisions such as Poison Control contact or ED transfer.)

Exposure History

• Timeline: [Exposure date/time; symptom onset latency; symptom progression pattern; time of clinical presentation]
• Route(s) and Site(s): [Route(s) of exposure and anatomic site(s) affected]
• Product Details: [Product/oil name; brand; form (pure oil / blend / roll-on / diffuser liquid / other); concentration or dilution status; ingredient list if available] (If unknown, document as unknown and record efforts to obtain details such as requesting label photo or asking patient to bring the bottle.)
• Quantity and Duration: [Estimated amount and duration of exposure]
• Setting and Circumstances: [Location and context pertinent to exposure assessment] (Include whether exposure was accidental or intentional if explicitly stated.)
• Prior Exposure/Sensitization: [History of prior exposure to same or similar products; atopy; fragrance sensitivity; prior reactions]

Clinical Presentation

Symptoms: [Symptoms by affected system (skin/mucosal, respiratory, neurologic, gastrointestinal/systemic) with timing and progression] (Include only systems with reported symptoms.)

Anaphylaxis Screening: [Airway compromise; breathing compromise; circulatory signs; rapid multi-system involvement] (When allergic features are present, explicitly document presence or absence of each indicator.)

Physical Exam: [Pertinent positive and negative findings relevant to exposure] (If telehealth, note exam limitations.)

Vital Signs: [Vital signs with times] (Include repeat values if systemic symptoms present.)

Diagnostics: [Tests performed and results] (Include only completed tests, not those pending or planned.)

Assessment

[Working diagnosis(es) with degree of certainty (suspected / likely / confirmed) and severity (mild / moderate / severe); differential diagnoses if clinically pertinent; clinical reasoning summary] (If anaphylaxis is documented, explicitly state the clinical criteria met and timing of progression. Use problem-oriented format for multiple diagnoses.)

Plan

• Decontamination: [Method; timing; performed by whom; clinical response] (Note if performed pre-arrival or in clinic.)
• Treatments: [Medication; dose; route; time given; clinical response] (List each intervention separately.)
• Observation: [Duration; reassessment times and findings]
• Consultations: [Poison Control case number and recommendations; other consultations] (Document if Poison Control was contacted.)
• Disposition: [home / observation / transfer / admission] [Rationale and patient condition at disposition]
• Return Precautions: [Red-flag guidance tailored to exposure: breathing difficulty, swelling, syncope, neurologic changes, symptom recurrence]
• Follow-Up: [Timing and provider; monitoring instructions]
• Avoidance Guidance: [Specific avoidance instructions for implicated product and related substances]
• Allergy List: [updated / not updated] [Changes made]
• External Reporting: [Poison Control / regulatory reporting / not indicated] (Document actions taken or rationale if not indicated.)