Aromatherapy Procedure Note (Topical Application)

Date & Time (Start): [Date and time of procedure start]

Date & Time (End): [Date and time of procedure end]

Location: [Clinical location]

Author: [Author name and credentials]

Order/Referral Source: [Ordering clinician or protocol reference]

Procedure Summary

[Brief 1–3 line synopsis: essential oil(s), dilution %, carrier, anatomic site, method, duration, and outcome including tolerance and any adverse effects]

Indication

Reason for topical application: [Symptom-focused indication] (Use clinically neutral language, e.g., promote comfort, support relaxation, support nausea coping.)

Baseline symptom rating: [0–10 score] (Omit if not documented.)

Pre-Application Safety Screen

• Allergy and sensitivity history: [Reviewed – none / Reviewed – positive for (list specific allergens) / Not reviewed] (If not reviewed, explicitly state "Allergy history not reviewed.")
• Skin integrity at intended site: [Intact / Non-intact (describe)]
• Respiratory sensitivity to fragrances: [None reported / Reports sensitivity (describe)]
• Concurrent devices or treatments near site: [None / Present (list)]

Consent

• Verbal consent: [Obtained / Declined / Consent documentation is missing] (Never infer consent.)
• Risks discussed: skin irritation, allergic contact dermatitis, phototoxicity risk for certain oils, headache or nausea from scent
• Alternatives offered: [Yes (describe) / No]
• Patient agreement to proceed: [Agreed / Declined]

Product Details

• Essential oil common name: [Required – specify exact identity]
• Botanical name: [Latin binomial if known]
• Source: [Hospital-approved / Patient-supplied / Other (specify)]
• Carrier type: [Required – specify carrier]
• Dilution percentage: [Required – exact % as labeled or prepared] (Never omit or estimate. For pre-diluted products, record labeled concentration.)

Patch Test

(Complete if performed or document why omitted. For new oils/products, include delayed reaction counseling.)

• Performed: [Yes / No]
• If performed – Site, dilution, observation period, result: [Details]
• If not performed – Reason: [Prior tolerance documented / Time constraints / Other (specify)]
• Mitigation if no patch test: [Lower dilution / Limited area / Increased monitoring / N/A]
• New product delayed-reaction counseling (24–72 hr ACD risk): [Provided / Not applicable]

Application Details

• Anatomic site with laterality: [Required – specify site and side]
• Application method: [Limited-area application / Hand massage / Spot application / Other (describe)]
• Duration: [Minutes]
• Applied by: [Clinician-applied / Self-applied / Caregiver-applied]

Patient Response

• Tolerance during procedure: [No adverse symptoms observed OR describe symptoms: burning, stinging, itching, headache, nausea, respiratory symptoms, visible skin changes]
• Post-application symptom score: [0–10 and change from baseline] (Include only if baseline documented.)
• Skin reassessment: [Findings at application site]

Adverse Effects

(Conditional – complete only if adverse effects occurred.)

• Status: [None observed or reported]
• If occurred – Description, timing, severity: [Details]
• Suspected trigger: [Component if known]
• Actions taken: [Product removed / Area cleansed / Cold compress / Medication / Clinician notified / Other]
• Outcome: [Resolved / Improving / Ongoing]

Patient Education

• Avoid contact with eyes and mucous membranes
• Wash hands after contact with treated area
• Stop use and notify clinician if delayed rash, breathing symptoms, or persistent headache/nausea occur
• Phototoxic-risk counseling: [Provided – sun/UV avoidance instructions given / Not applicable] (Required if any phototoxic oil used, particularly citrus oils.)

Plan

• Repeat plan: [May repeat per protocol / Do not repeat pending evaluation / Other (specify)]
• Escalation criteria: [Criteria for discontinuation or clinician notification]
• Follow-up: [Timeframe or conditions for reassessment]