Aromatherapy Intervention Note (Diffusion/Environmental Use)

Date/Time: [Date and time of intervention]

Provider: [Name, credentials, department]

Location: [Facility, unit, room/bed; shared vs private room]

Indication & Authorization

[Reason for aromatherapy, intended purpose, and patient-centered goal] (Write 1–3 sentences. Include trigger/initiator [patient request / family request / staff suggestion / protocol], intended purpose [comfort / symptom support / odor-related comfort], and baseline symptom rating if applicable. Use quotation marks for the patient's own words. Document consent obtained from the patient. If in a shared room, document roommate notification and whether roommate [consented / declined]; if declined, note diffusion was not initiated and alternative offered. State that patient and any roommate were advised they may request discontinuation at any time. If diffusion cannot proceed for any reason, document the reason and omit remaining sections.)

Safety Screen & Intervention

Safety Screen: [Patient-specific risk factors] (Briefly document respiratory history, fragrance/scent sensitivity, prior intolerance to essential oils, and relevant allergies. Use phrasing like "denies history of" or "chart review shows no" rather than asserting absence. If any contraindication identified, document diffusion not performed with reason and alternative offered, then omit intervention details.)

Device & Infection Prevention: [Device type: water-based ultrasonic / nebulizing / fan-cartridge / passive] — [Cleaning performed per policy: yes / no] — [Water source if applicable: sterile / distilled / tap]

Intervention: (Complete only if proceeding with diffusion.)

• Substance: [Essential oil common name and/or blend name] — [hospital-stock / patient-owned] (If identity unknown or unlabeled, do not initiate; document reason and omit remaining details.)
• Parameters: [Drops or mL added, device setting, run mode: continuous / intermittent]
• Timing: Start [time] — Stop [time / ongoing with planned reassessment time and stop criteria]

Response & Plan

Reassessment: [Time since start] — [Patient-reported and/or observed response] (Include symptom rating change from baseline; use brief patient quote in quotation marks if meaningful. Screen for intolerance: coughing, throat/eye irritation, headache, wheeze, chest tightness, worsening nausea. Classify as [tolerated / not tolerated]. Do not chart "effective" without specifying what improved and how assessed.)

Intolerance Event: [Chronological narrative if intolerance occurred] (Include symptom onset timing, specific symptoms, actions taken [diffusion stopped / device removed / room ventilated], notifications made, disposition, and whether scent intolerance should be added to patient record. Omit this field if tolerated.)

Plan: [Continue / stop] (If continuing, specify parameters and next reassessment time. If stopping, document non-scent alternatives offered.)