Inpatient Complementary Therapy Nursing Note (Aromatherapy)

Header

Date/Time: [auto-populated or entered]

Unit/Room/Bed: [auto-populated]

Nurse: [name and credentials]

Therapy Type: Complementary Therapy – Aromatherapy

Authority: [Nursing protocol/standing order / Provider order / Patient-requested per policy]

Indication & Consent

Comfort goal: [promote relaxation / support rest/sleep readiness / support overall well-being / other comfort goal]

Trigger for intervention: [patient request / nursing assessment / family request with patient assent / care plan pathway]

Scent preference: [patient-stated preference or refusal] (Use direct quotes for preference/refusal statements.)

Education provided: [yes / no – reason] (Brief education on what to expect; stop/notify if headache, nausea, dyspnea, or irritation; external use only.)

Consent: [verbal consent obtained / unable to obtain – reason]

Safety Screening

• Allergy/fragrance sensitivity: [negative / positive – specify / unable to assess – reason]
• Respiratory risk: [none identified / present – specify condition and action taken / unable to assess – reason]
• Neurological considerations: [no migraine/seizure history / history present – specify and prior aromatherapy tolerance / unable to assess – reason]
• Pregnancy status: [not applicable / not pregnant / pregnant – specify trimester / unable to assess – reason]
• Skin integrity (if topical): [intact / compromised – describe / not applicable]
• Roommate/environmental sensitivity: [no concerns / sensitivity reported – specify / not applicable]
• Oxygen/fire safety (if supplemental O2): [not applicable / precautions reviewed / concern identified – action taken]

Screening outcome: [cleared for aromatherapy / contraindication identified – specify and action taken / screening incomplete – reason and conservative action per policy]

Intervention

Product type: [inhaler / patch / passive inhalation / topical]

Essential oil(s): [name(s)]

Product source: [hospital-endorsed product / patient's personal product per policy]

Lot/Batch # and Expiration: [if required by facility policy]

Single-patient use confirmed: [yes / N/A]

Administration start time: [time]

Route/Method specifics: [placement/distance for inhalation / site for patch or topical / placement for passive diffusion]

Duration of exposure: [minutes / ongoing]

Hand hygiene: [performed before and after]

Removal/Disposal: [timeframe and method per policy / not applicable]

Assessment & Response

Pre-intervention: Time: [time]; Scale: [anxiety/stress / nausea / pain / relaxation / other]; Rating (0–10): [score / unable to rate – reason and observable descriptors]

Post-intervention: Time anchor: [15 min post / at removal / other]; Same scale rating (0–10): [score / unable to rate – reason]

Patient-reported response: [response] (Use direct quotes when available.)

Tolerance: [tolerated well / mild transient symptoms – specify / adverse effect occurred]

If adverse effect: Reaction type: [headache / nausea / dyspnea / skin irritation / scent intolerance / other]; Actions: [source removed, supportive measures]; Notifications: [provider / charge nurse / RT / other]; Incident report: [completed / not indicated]; Outcome: [resolved / improving / persistent]

Communication & Plan

Notifications: [primary RN if different / provider / relevant team members]

Care plan updated: [yes / no]

Allergy/sensitivity list updated (if reaction): [yes / no / N/A]

Ongoing plan: [may repeat PRN per protocol / scheduled use / discontinued / patient declines future use]

Patient preference for future: [scent(s) and conditions] (Document in direct quotes.)

Next reassessment (if product remains in place): [timeframe]

If not performed: [patient declined / contraindication identified / product unavailable / screening incomplete / other – specify] (Only include if aromatherapy was offered but not delivered.)

(Do not chart prospectively. All entries must be dated, timed, and authenticated per CMS and facility requirements.)