Aromatherapy Session Note (SOAP)

Date/Time: [Date and time]

Patient: [Patient name/identifier]

Provider: [Name, credentials]

Visit Type: [Initial / Follow-up]

Setting: [outpatient / inpatient / telehealth coaching / other]

Consent: [Statement confirming patient agreed to aromatherapy, understands complementary/supportive role, and any preferences or restrictions]

Subjective

[Chief concern and goals in patient's own words] (1–3 sentences; specify whether goals are immediate, short-term, or longer-term.)

Symptoms and baseline: [Primary symptom(s)] — baseline: [value]/10 (Use consistent numeric scale throughout.)

Relevant history: [Allergies/sensitivities, respiratory history if inhalation planned, skin integrity if topical planned, pregnancy/lactation status when applicable] (Include only items relevant to planned route.)

Prior aromatherapy: [Previous exposure, tolerance, adherence, home use results] (Include for follow-up visits.)

Objective

General observations: [Appearance, distress level, affect, breathing pattern, skin status at intended application site if topical]

Pre-session ratings: [Relevant domains and values using same numeric scale as Subjective]

Safety screening: [For each relevant item—allergy/sensitivity, respiratory risk, seizure/migraine history, pregnancy status, skin integrity/photosensitivity—use status labels: Denies / Reports / Unknown / Not assessed, with details] (If Unknown or Not assessed, document reason, mitigation taken, and follow-up action.)

Assessment

[Brief synthesis linking findings to clinical rationale for aromatherapy as supportive care]

Issues/goals addressed: [e.g., stress/tension, sleep initiation difficulty, nausea, discomfort, mood support]

Appropriateness: [Appropriate today / Deferred] — [rationale and risk controls selected: route, dilution limits, duration, ventilation, monitoring]

Progress: [improved / stable / worsened] — [evidence] (Include for follow-up visits.)

Plan

Intervention: [Modality/route], [product common name (botanical name)], [concentration/dilution with carrier], [dose/exposure details including duration and site if topical]; avoided: [agents/routes avoided and reason if applicable]

Response: [Observed response, tolerance, post-session rating], [adverse effects and actions taken if any] (Distinguish post-session from pre-session values.)

Education: [Safe use principles covered, expected effects, stop criteria]

Home program: [Route, specific product with botanical name, dilution, frequency, duration limits, key safety instructions including "do not" statements] (Include if recommending at-home use.)

Follow-up: [Timing, what to monitor, escalation criteria]

Signature: [Provider signature, credentials, date/time]