Informed Consent Note (Aromatherapy)

Informed Consent Note (Aromatherapy)

Date/Time: [Date and time of documentation]

Location/Setting: [Location or setting]

Author and Credentials: [Name, role, credentials]

Ordering/Responsible Practitioner: [Name and role / same as author / protocol reference] (Include only if different from author or when performed under a standing order.)

Clinical Context and Indication

[Clinical context and indication for aromatherapy] (In 1–3 sentences, state why aromatherapy is being offered, the clinical indication if present, and any patient-stated goals in their own words. State that aromatherapy is offered as a supportive comfort measure and not a substitute for indicated medical treatment. If there is no specific symptom indication and the request is purely for comfort/well-being, state this.)

Consent Provider and Capacity

Consent provided by: [Patient / Legally authorized representative: relationship and basis for authority]

Capacity: [Capacity assessment statement] (Confirm the individual demonstrates understanding, can communicate a choice, and is acting voluntarily. For minors, document assent when developmentally appropriate.)

Interpreter: [None / Language and interpreter identification]

(If capacity cannot be confirmed, document that aromatherapy was deferred and why. Never infer consent from participation or tolerance alone.)

Intervention Description

Route/Method: [Inhalation via personal inhaler / inhalation via aroma tab / passive room diffusion / topical application with carrier oil / other: specify]

Essential oil(s) or blend: [Generic oil name(s) or blend description] (Use generic oil names rather than brand marketing language. If the specific oil has not yet been selected, document the options offered and note that final selection will be recorded in the Decision and Scope of Consent section.)

Planned duration and intensity: [Approximate duration and exposure level]

Topical application details: [Body area(s); dilution ratio; carrier oil] (Include only if topical route is authorized. Confirm that appropriate dilution will be used and that eyes, mucous membranes, and broken skin will be avoided.)

Shared space considerations: [Ventilation and room considerations] (Include only if diffusion is planned in a shared space.)

Benefits and Limitations

Intended purpose and potential benefits: [Expected benefits] (Frame benefits as possibilities, not guarantees, such as comfort, relaxation, supportive symptom relief, or pleasant sensory experience.)

Limitations: [Limitations discussed] (Acknowledge that evidence varies, individual responses differ, and aromatherapy is not curative. State that the patient may stop at any time.)

Risks Disclosed

• Topical risks: [Skin irritation; allergic contact dermatitis or sensitization; phototoxicity with sun exposure when using phototoxic oils] (Include only if topical route is planned.)
• Inhalation/diffusion risks: [Nose/throat irritation; cough; potential shortness of breath or wheezing in individuals with respiratory conditions] (Include only if inhalation or diffusion is planned.)
• General risks: [Headache or migraine triggering; nausea or dizziness; product variability or unexpected sensitivity]

[Safety instructions given] (Document that the patient was instructed to report any symptoms immediately and that aromatherapy will be stopped if adverse effects occur.)

Alternatives Discussed

• Decline aromatherapy / no additional intervention
• [Non-scented comfort measures discussed: breathing techniques, guided imagery, music therapy, repositioning, environmental modifications]
• [Other integrative options available: massage without oils, acupressure, mindfulness] (Include only options available in the current setting.)

Questions and Understanding

Questions: [Patient questions and responses provided] (If no questions, document that the patient was given the opportunity to ask questions and had none at this time.)

Understanding: [Comprehension confirmation] (Confirm that the patient verbalized understanding of the purpose, risks, alternatives, and the right to stop at any time. If teach-back was used, briefly note what the patient stated back.)

Decision and Scope of Consent

Decision: [Consent given / Declined / Deferred]

If consent given:

• Authorized route(s): [Inhalation via personal inhaler / inhalation via aroma tab / passive room diffusion / topical application with carrier oil / other: specify]
• Selected oil(s)/blend: [Generic oil name(s) or blend description]
• Patient boundaries/preferences: [Patient-specified limits or preferences, if any]

(State that consent is voluntary and may be withdrawn at any time.)

If declined: [Reason if provided without pressure; alternative measures accepted instead]

If deferred: [Reason for deferral and any next steps]

(If the plan changes to a different route, document that new consent was obtained for the new route.)

Safety Screening

• Allergy or sensitivity to fragrances/essential oils: [None known / Details]
• Respiratory conditions: [None / Asthma / COPD / Reactive airway / Current symptoms: specify]
• Migraine or odor sensitivity: [None / Details]
• Skin integrity concerns: [None / Areas to avoid / Details] (Include for topical application.)
• Stop criteria reviewed: [Headache; nausea; coughing; wheezing; skin irritation]
• Monitoring: [Who will monitor during the session]

Outcome

[Outcome of aromatherapy session] (If aromatherapy was administered during this encounter, document that it was provided, patient tolerance, any adverse symptoms, and actions taken if symptoms developed such as stopping therapy, providing fresh air, or notifying the clinician. If aromatherapy was not performed during this encounter, state this.)

Signatures and Attestations

(Include this section only if required by organizational policy for aromatherapy consent. If written signatures are not required, omit this section and rely on standard EHR author authentication.)

• Patient or Legally Authorized Representative Signature: [Name/Signature] [Date/Time]
• Witness Signature: [Name/Signature] [Date/Time] (If required by policy.)
• Clinician Attestation: I explained the nature, purpose, risks, benefits, and alternatives; assessed understanding; answered questions; and documented consent. [Clinician Name/Signature] [Date/Time]