Allergen Immunotherapy Injection Procedure Note (SCIT)

Patient: [Patient name (Last, First); DOB: MM/DD/YYYY]

Date of Service: [Date]

Clinic/Location: [Clinic or site]

Ordering Clinician: [Name, credentials]

Administered By: [Name/initials, credentials]

SCIT Program Context

[Current phase: build-up / maintenance]; [Interval since last injection]; [Current vial set identifier(s)]; [Last administered dose(s) relevant to today] (Keep concise to inform safe dosing. Do not restate the full treatment plan.)

Pre-Injection Safety Screen

• [Intercurrent illness: fever / acute infection / feeling unwell: yes / no] (If yes, briefly describe.)
• [Systemic reaction since last injection: yes / no] (If yes, describe timing, symptoms, treatment sought, and outcome.)
• [New or worsening allergic symptoms since last visit: yes / no] (If yes, describe.)
• [Relevant medication changes since last visit: yes / no] (If yes, list changes including beta-blockers, ACE inhibitors, asthma medications, oral steroids.)

Asthma assessment (Include only if patient has asthma history.)

• [Current asthma control status: well controlled / partly controlled / uncontrolled]
• [Increased rescue inhaler use or recent exacerbation: yes / no] (If yes, describe.)
• [Peak expiratory flow if measured: current value; patient baseline; % of baseline] (Withhold injection during acute exacerbation or when PEF is significantly below baseline per local policy.)

Clearance decision: [Cleared for injection / Injection held or deferred] (Do not assume clearance; explicitly document decision.)

(If held/deferred:) [Reason]; [Disposition: reschedule / clinician evaluation / urgent care / ED]; [Clinician notified: name/time]

Vial Verification

• [Two-patient-identifier verification performed: yes] (Identifiers used: [e.g., name + DOB / name + MRN])
• [Correct patient-specific vial(s) confirmed: yes] (List each vial with practice-defined identifier: [Vial ID/dilution/color code]; [Expiration date] (optional))

Injection Administration

(If only one injection, document as a single entry. If multiple injections, use a numbered list.)

1. [Injection #1]

   • [Vial ID/Dilution]
   • [Dose (mL)]
   • [Injection site: right posterior arm / left posterior arm / right lateral arm / left lateral arm / other]
   • [Time administered: HH:MM]
   • [Dose different from protocol: yes / no]

   (If dose adjusted:) [Planned dose]; [Actual dose]; [Reason: extended interval / new vial / prior reaction / seasonal flare / asthma symptoms / clinician-directed / other]; [Clinician authorization obtained: yes / no / N/A]; [Authorizing clinician if applicable]

2. [Injection #2] (Include only if administered.)

   • [Vial ID/Dilution]
   • [Dose (mL)]
   • [Injection site]
   • [Time administered: HH:MM]
   • [Dose different from protocol: yes / no] (If yes, include reason and authorization.)

Post-Injection Observation

• [Observation start time: HH:MM] (Typically time of first injection.)
• [Prescribed observation duration: 30 minutes / other] (Default 30 minutes per AAAAI guidelines; longer if high risk.)
• [End/Discharge time: HH:MM]
• [Observation completed in clinic: yes / no]

(If observation not completed:) [Reason: left early / ED transfer / other]; [Counseling provided]; [Disposition]

[Vital signs: BP; HR; RR; SpO2] (Required if systemic symptoms occur or medications administered; optional for routine uneventful visits.)

Reactions

(Do not infer absence of reaction. Explicitly document.)

• [No local reaction observed: yes / no]
• [No systemic reaction observed: yes / no]

Local reaction (Complete only if occurred.)

• [Injection site affected]
• [Onset timing (minutes post-injection)]
• [Size: wheal/erythema diameter in mm or qualitative description]
• [Symptoms: pruritus / pain / swelling / other]
• [Treatment provided and time]
• [Outcome at discharge]

Systemic reaction (Complete only if occurred.)

• [Time of first symptom onset (minutes post-injection)]
• [First symptom(s) noted] (Use patient quotes for clinically significant subjective symptoms.)
• [Organ systems involved: cutaneous / respiratory / GI / cardiovascular / neurologic]
• [Severity grade per organizational grading system]

Treatments administered (Complete only if given.)

• Epinephrine: [Time]; [Dose (mg)]; [Route: IM]; [Site: anterolateral thigh / other]
• Other therapies with time and dose: [Antihistamine]; [Albuterol]; [Corticosteroid]; [Oxygen]; [IV fluids]
• [EMS activation: yes / no] (If yes, time and transport method.)

Reaction narrative: [Brief description of reaction progression, response to treatment, and final status]

Reaction disposition: [Discharged stable after extended observation / Transferred to ED (ambulance / private vehicle) / Hospitalized]

Disposition and Next Dose Plan

• [Discharge status: stable / symptoms resolved / improving]
• [Delayed reaction counseling provided: yes / no] (Include return precautions.)
• [Epinephrine auto-injector availability and instruction confirmed: yes / no / N/A]
• [Next scheduled date or interval]
• [Next dose plan: advance / repeat / reduce / hold] with [Planned dose per vial]
• [Conditional instructions if any] (e.g., hold next dose pending clinician review if delayed symptoms occur.)
• [Clinician notification if reaction or major dose change: name/time]

(After systemic reaction, document that clinician review and authorization is required before next injection.)

(Safety-critical: Explicitly document asthma screening for patients with asthma history, observation completion status, and reaction assessment. Never infer dose, dilution, injection site, observation duration, presence or absence of reaction, or medications administered. If the patient leaves before completing observation or declines recommended care, document the discussion and patient's decision.)