Allergy and Immunology Progress Note

Date of Service: [Date]

Patient Name, DOB, MRN: [Full name] | [DOB] | [MRN]

Clinician: [Clinician name, credentials]

Reason for Visit: [Brief phrase anchoring today's focus]

Chief Concern

[Primary symptom or condition focus with follow-up framing; include patient's own words in quotes when clinically meaningful]

Interval History

[Longitudinal update since last allergy/immunology visit] (Begin with date of last A/I visit, prior plan anchor, and any interim exacerbations or significant events such as ED visits, hospitalizations, steroid bursts, or anaphylaxis. If last visit date or prior plan is unavailable, state this explicitly.)

(For each active condition relevant to today's visit, document current control status, recent symptoms or events, treatment adherence and tolerance, and objective anchors when available. Include only conditions addressed today.)

• [Condition]: [Control status]; [recent symptoms/events]; [adherence/tolerance]; [objective anchors if available]

New allergic reaction since last visit: [Yes / No / None reported]

(If yes, document: suspected trigger and context; timing relative to exposure; symptoms by system; treatment used including epinephrine timing if administered; disposition and outcome.)

Medications & Allergies

Current Medications: [Medication list with dose, route, frequency] (Note changes made today: started / stopped / dose adjusted / continued. Include adherence and tolerance notes only if clinically relevant. If reconciliation could not be completed, document reason.)

Allergy List: [Verified allergens with reaction phenotypes] (If NKDA, confirm this was affirmatively reviewed. Note any label updates or clarified phenotypes.)

Objective

Vitals: [Relevant vitals as obtained] (Document "not obtained" if applicable.)

Exam: [Problem-focused findings by pertinent systems] (Document only what was examined today. Include nasal mucosa, oropharynx, conjunctiva for rhinitis; respiratory exam for asthma; skin for urticaria/eczema as relevant.)

Data: [Relevant results reviewed or obtained today with dates and interpretation] (May include spirometry, FeNO, allergy skin testing, serum IgE panels, eosinophils, tryptase, imaging as applicable.)

Procedures: (Include only if performed today.)

• Skin testing: [Indication]; [agents/method]; [results and interpretation]; [reactions and treatment if any]; [disposition]
• Immunotherapy injection: [Vial identifier]; [dose]; [site]; [observation duration]; [local/systemic reaction assessment]; [treatment if any]; [next dose plan]
• Drug/food challenge: [Indication]; [agent and protocol]; [patient response]; [reactions and treatment if any]; [outcome/disposition]
• Biologic administration: [Agent]; [dose/route/site]; [observation]; [adverse events if any]; [disposition]

Assessment

(Numbered problem list ordered by clinical priority. For each problem, include diagnosis with phenotype when relevant, current control status, and key supporting data. Include brief differential only when diagnostic uncertainty exists.)

1. [Problem]: [Diagnosis with phenotype] — [control status]; [key supporting data]

Plan

(Mirror the Assessment problem list. For each problem, include applicable elements: medication changes with rationale; testing/monitoring ordered; education provided with documentation of patient understanding for high-risk items; safety instructions and return precautions; referrals; follow-up interval.)

1. [Problem]: [Medication changes]; [testing/monitoring]; [education]; [safety/return precautions]; [referrals]; [follow-up]

Anaphylaxis risk management: (Include for patients with anaphylaxis risk.) [Epinephrine auto-injector: prescribed / available]; [expiration]; [training provided: yes / no]; [action plan reviewed: yes / no]

E/M Coding Support: [MDM-based / Time-based] — [If MDM: problems addressed and risk level] [If time-based: total clinician time on date of service, excluding separately billed procedures]