Aromatherapy Procedure Note (Inhalation)

Date/Time: [Date and time of procedure]

Location: [Care setting / unit / room]

Author/Credentials: [Name, role, credentials]

Procedure Summary: Inhalation aromatherapy administered for [symptom target(s)] using [delivery method] with [oil(s)] [number of drops] for [duration].

Indication

[Primary symptom target(s) and relevant clinical context, including intended goal] (Brief 1–2 sentences; do not duplicate history documented elsewhere.)

Contraindication/Precaution Screening

• Allergy or sensitivity to essential oils or fragrances: [yes / no / N/A] — [comments]
• Respiratory conditions (asthma, COPD, reactive airway, current dyspnea, oxygen use): [yes / no / N/A] — [comments]
• Odor-triggered symptoms (migraine, severe nausea with odor aversion): [yes / no / N/A] — [comments]
• Ability to follow instructions / altered mental status: [yes / no / N/A] — [comments]
• Environmental concerns (shared room, nearby fragrance-sensitive individuals): [yes / no / N/A] — [comments]

Screening Outcome: [No contraindications identified / Precautions present: [specify] — Mitigation: [specify] / Contraindication identified — aromatherapy not administered: [reason]] (Required; must not be omitted or inferred.)

Consent

[Verbal / Written] consent obtained. Patient preference: [aroma preference(s) and any aversions]. Risk counseling provided including possible irritation, cough, headache, nausea worsening, and allergic reaction; patient instructed to stop if symptoms occur.

Agent & Administration

Delivery Method: [personal inhaler / sealed cotton ball or wick / aromatherapy patch or tab with location]

Oil(s): [Common name(s); botanical name(s) if known; if blend, list components]

Dose: [Number of drops total; specify per oil if blend]

Source: [facility-supplied / patient-supplied]

Start Time / Duration: [Start time and duration or stop time]

Technique: [Patient positioning, distance from nose, breathing instructions, frequency/pattern, stop criteria communicated]

Supervision: [continuous observation / intermittent checks / patient self-administered after instruction] (If self-administered, document that safe technique was demonstrated and understood.)

Lot/Manufacturer/Expiration: [If dictated or if adverse event occurred; otherwise omit]

Assessment

• Pain: [pre-rating 0–10] → [post-rating 0–10] (post obtained at: [time anchor]) (Use "Not assessed — not a target symptom," "Not present at baseline," or "Unable to rate: [reason]" as applicable.)
• Anxiety: [pre-rating 0–10] → [post-rating 0–10] (post obtained at: [time anchor])
• Nausea: [pre-rating 0–10] → [post-rating 0–10] (post obtained at: [time anchor])

Patient-Reported Response: [Brief summary in patient's words, if clinically useful; note if ineffective or symptoms worsened]

Continuation Preference: [wishes to continue / declines further use]

Tolerance & Adverse Events

Tolerance: [e.g., tolerated well with no cough or irritation / stopped early due to [reason]]

Adverse Events: [None / Description including severity, suspected trigger, actions taken, patient status after intervention, and notifications made] (Required even if none occurred; do not omit.)

Plan

Disposition: [Patient status after procedure]

Ongoing Use: [continue PRN / repeat session scheduled / discontinue / modify approach: [specify]]

Safety Reminders Provided: [no ingestion; avoid mucous membrane contact; stop with irritation or worsening; safe storage/disposal]

Follow-up: [Follow-up plan if applicable]

(Required elements: indication, screening outcome, consent, oil(s)/dose/method, supervision, pre/post ratings or explicit reason unavailable, adverse events status. If required information is not dictated, insert "[Not documented — requires completion]." Never infer screening results, consent, oil identity, dose, ratings, or adverse event status. If post-rating timing not specified, note "timing not specified." This template is for inhalation aromatherapy only — not for room diffusion, topical application, or ingestion.)