Anaphylaxis Evaluation Note

Header

Encounter Date/Time: [Encounter date and time] ; Location Type: [ED / urgent care / inpatient / clinic]

Event Date/Time: [Exact event date and time / Time of onset unknown; patient unsure] (If unknown, explicitly document uncertainty rather than leaving blank.)

Time Since Event: [Elapsed time from symptom onset to encounter] (If multiple events, specify which event this refers to.)

History Sources: [Patient / EMS / family / caregiver / medical records] — [Reliability: reliable / limited / unreliable] — [Interpreter used: yes (language) / no]

Allergy List Reviewed: [Reviewed and up to date / Reviewed and updated during visit / Reviewed—updates pending] (Confirm allergy banner was reviewed; specify any changes made.)

Chief Complaint

[Patient-stated reason for visit in one concise line]

Event Summary

[3–6 sentence overview: suspected trigger category with certainty qualifier, organ systems involved, severity markers (hypotension, hypoxemia, airway compromise, syncope), treatments received with epinephrine timing if known, clinical course including resolution/recurrence and disposition. Explicitly state whether anaphylaxis criteria were met versus suspected only.]

History of Present Illness

Exposure Inventory

Foods/Ingestions: [Candidate foods, sauces/mixed dishes, supplements] — [Time from exposure to onset] — [Amount] — [Previously tolerated: yes / no / unknown] — [Context: home / restaurant / packaged; cross-contact risk] — [Cofactors: exercise / alcohol / NSAID / acute illness / none]

Medications: [Agent, new vs chronic, dose, route, timing relative to onset] — [Previously tolerated: yes / no / unknown]

Venom/Insect: [Sting vs bite, number, anatomic location, insect identification if known] — [Time relative to onset]

Latex/Contact: [Gloves / medical devices / balloons / other] — [Type and duration of contact] — [Time]

Exercise-related: [Exercise intensity/type] — [Temporal relation to meals/NSAIDs/alcohol] — [Environmental conditions]

Occupational/Environmental: [Relevant exposures] — [Setting] — [Time]

(Document all plausible exposures within the relevant time window. If information is incomplete, explicitly record what was asked and what remains unknown.)

Symptom Timeline

• [Time point 1 (clock time or minutes from exposure)]: [Symptoms by organ system] — [Objective findings: BP, HR, SpO2, wheeze/stridor, rash] — [Interventions and response]
• [Time point 2]: [Symptoms/findings] — [Interventions/response]
• [Additional time points as needed]: [Progression/resolution/recurrence]

[Brief narrative interpretation linking temporal relationships to likely trigger(s); explain uncertainties or alternative possibilities.]

Severity Characterization

Airway: [Throat tightness / voice change / stridor / tongue or lip swelling / none] — Breathing: [Dyspnea / wheeze / hypoxemia / increased work of breathing / none] — Circulation: [Hypotension / syncope / collapse / shock / none] — Skin/Mucosal: [Urticaria / flushing / angioedema / none] — GI: [Repetitive vomiting / severe cramping / diarrhea / none] — Neurologic: [Confusion / sense of impending doom / none] (Explicitly document absence of life-threatening features when not present. Note: absence of skin findings does not exclude anaphylaxis.)

Pre-Hospital Interventions

Epinephrine self-administered: [Device/brand, dose, site, time, number of doses, response, adverse effects / none] — Other: [Antihistamines / inhalers / positioning / EMS activation with arrival time / none] (Attribute details to source: patient recall vs EMS report.)

Acute Treatments

(Include for acute-care encounters; omit for post-event follow-up.)

Epinephrine: [Time(s), dose(s), route, site, clinical response, adverse effects] (Document as primary therapy; if not given, document clinical rationale.)

Airway/Respiratory Support: [Oxygen delivery method and FiO2] — [Nebulized bronchodilators with doses/times] — [Airway interventions]

Circulatory Support: [IV/IO fluids with volume and times] — [Vasopressors: agent, dose, timing]

Adjunct Medications: [Antihistamines: agent/dose/time] — [Corticosteroids: agent/dose/time] — [H2 blockers] — [Antiemetics] — [Other] (Adjuncts are supplementary to epinephrine. If times or doses uncertain, document source and uncertainty.)

Observation and Disposition

(Include for acute-care encounters; omit for post-event follow-up.)

Resolution status: [Fully resolved / Partially improved / Persistent symptoms] — Time of resolution: [Time]

Recurrence after initial improvement: [Yes / No] — Details: [Timing, features, treatments if applicable]

Observation duration: [Hours observed] — Rationale based on risk factors: [Multiple epinephrine doses / severe respiratory compromise / poorly controlled asthma / delayed presentation / limited access to emergency care / late evening discharge / other]

Disposition: [Home / Admission with level of care / Transfer] — Discharge counseling documented: [Biphasic reaction risk discussed; actions if symptoms recur; epinephrine-first instruction provided]

Relevant History

Prior anaphylaxis: [Number of episodes, approximate dates, suspected triggers, severity, epinephrine use / none known]

Atopic disease: [Allergic rhinitis / eczema / food allergy / none] — Asthma: [Controlled / partially controlled / uncontrolled / none] — [Recent exacerbations or hospitalizations]

Medications affecting management: [Beta-blockers / ACE inhibitors / MAO inhibitors / none]

Cardiovascular disease: [Relevant conditions / none]

Mast cell disorder history/signs: [Baseline flushing / recurrent idiopathic anaphylaxis / prior elevated tryptase / systemic symptoms / none] (Include only history affecting trigger evaluation, severity risk, or management.)

Physical Examination

Vital signs: [Time-stamped vitals; include serial vitals for acute care]

General: [Appearance, distress level]

Airway: [Patency, voice quality, stridor, oropharyngeal/tongue/lip swelling]

Breathing: [Work of breathing, breath sounds, wheeze, SpO2]

Circulation: [Pulses, capillary refill, perfusion status]

Skin/Mucosa: [Urticaria, flushing, angioedema—note distribution and extent]

Other findings: [GI tenderness, neurologic status, additional relevant systems]

Diagnostic Data

Records Reviewed

[EMS run sheet / ED note / medication administration record / clinic records — with source and date for each]

Laboratory Testing

Serum tryptase (acute): [Result(s) with units] — Time from symptom onset: [Hours from onset for each sample, not clock time alone] — Interpretation: [Elevated / normal; clinical relevance]

Baseline tryptase: [Obtained / planned at least 24–48 hours after symptom resolution / not indicated] (If deferred, document rationale.)

Allergy Work-up

(Include for post-event follow-up; may note plan for acute-care encounters.)

Testing planned/completed: [sIgE/component testing / skin testing / venom panel / drug skin testing / graded challenge] — Timing: [Date or waiting period] — Prerequisites: [Antihistamine hold / beta-blocker considerations / steroid washout]

Immunotherapy/Desensitization: [Venom immunotherapy indicated and discussed / drug desensitization plan / not indicated] (If testing deferred due to timing, medication interference, or safety concerns, document why and plan to revisit.)

Assessment

Anaphylaxis Evaluation

Criteria determination: [Confirmed / Highly likely / Possible / Unlikely] — Supporting elements: [List involved organ systems and objective findings with source attribution] (If treated as high-risk allergic reaction without meeting full criteria, document rationale.)

Most likely trigger: [Trigger] — Confidence: [High / Moderate / Low]

Alternative triggers considered: [List with brief reasoning]

Non-anaphylaxis diagnoses considered: [Vasovagal reaction / asthma exacerbation / panic attack / hereditary angioedema / other] — [Reasoning for/against]

Severity summary: [Number of epinephrine doses required, airway intervention, hypotension/shock, ICU admission, complications]

Plan

Epinephrine Prescription and Education

Device/dose: [Epinephrine autoinjector with weight-based dose selection] — Quantity: [Two devices; rationale for carrying both] — Training: [Brand-specific demonstration performed; patient/caregiver return demonstration confirmed] — Instructions: [Use at first sign of systemic reaction; do not delay for antihistamines; activate emergency services after use; positioning after injection; when to administer second dose]

Trigger Avoidance

Interim avoidance instructions: [Specific avoidance pending evaluation completion] — Cross-contact precautions: [Key points for food triggers] — Medication alternatives: [Class and generic names to avoid; safe alternatives identified]

Follow-up and Referral

Allergy referral: [Placed / existing relationship / not indicated] — Planned testing: [What, when, prerequisites] — Records to obtain: [EMS / ED / pharmacy / other]

Comorbidity Management

Asthma optimization: [Controller adjustments / action plan reviewed / rescue inhaler access confirmed] — Medications affecting anaphylaxis management: [Beta-blocker/ACE inhibitor adjustment discussed with risk-benefit / no changes needed] (Include only if applicable.)

Chart Update

Allergy list: [Updated with confirmed allergy vs suspected trigger under evaluation; reaction phenotype and severity documented] — Problem list: [Anaphylaxis added/updated with suspected trigger and event date]

Follow-up and Return Precautions

Follow-up: [Timeframe and provider]

Use epinephrine and seek emergency care immediately if: [Symptoms of systemic reaction, breathing difficulty, throat tightness, dizziness/syncope, rapid symptom progression]

Contact provider urgently if: [New or worsening symptoms after initial resolution, questions about epinephrine use, delayed symptoms]