Patch Testing Procedure Note (Application)

Date/Time: [Date and start time of application]

Patient: [Patient name and identifiers per organizational standard]

Clinician: [Clinician name and credentials]

Procedure: Patch Test Application

Indication

[Brief clinical context for patch testing] (1–2 sentences summarizing dermatitis distribution, duration, severity, suspected exposures, and clinical question. If a same-day E/M note contains detailed history, reference it instead of duplicating.)

Pre-Procedure Site Examination

Application site: [upper back / other: [specify]]

Skin condition: [intact and suitable for testing / findings requiring consideration: [specify]] (If active dermatitis, excoriations, sunburn, or other factors require alternate site placement, document reason and alternate location.)

Relevant topical agents near test area: [none / [specify agent, location, timing]]

Consent

[Informed consent obtained: [written / verbal] from [patient / guardian (relationship: [specify])]] (Document that risks—localized dermatitis, itching, blistering, pigment changes, rare flare or infection—were discussed, alternatives reviewed, and questions answered.)

(If consent not obtained, document reason and that the procedure was not performed.)

Test Plan

• Standard/baseline series: [series name(s)]
• Supplemental series: [none / cosmetics / metals / occupational / topical medications / other: [specify]]
• Patient's own products tested: [none / [list items]]
• Total number of patch tests applied: [integer required for billing]
• Allergen detail: [listed below / see attached panel manifest / grid recorded in media tab]

Application Details

• Site: [upper back / other: [specify with laterality/orientation]]
• Skin preparation: [cleaned and dried] [hair trimmed/shaved: [yes / no / n/a]]
• Marking method: [method used to mark sites for later readings] (Position map documented in: [diagram in note / grid coordinates / photograph in chart / attached manifest])
• Chamber/dressing system: [Finn Chambers / IQ Ultra / T.R.U.E. Test / other: [specify]]
• Tolerance: [patient tolerated procedure]
• Complications: [none / [specify]]

Patient Counseling

The following instructions were reviewed with the patient:

• Keep patches in place until removal appointment
• Keep the area completely dry (no showering, bathing, or swimming; sponge bath only)
• Avoid heavy sweating, vigorous exercise, and heat exposure
• Do not scratch, rub, or apply any products to the test area
• Avoid sun/UV exposure to the test area
• Expected: mild itching and redness at some sites
• Contact clinic for: severe pain, extensive blistering, spreading rash, fever, drainage, or systemic symptoms

Written instructions provided: [yes / no] | Patient verbalized understanding: [yes / no]

(If counseling not completed, document reason and plan to provide instructions.)

Reading Schedule

• Patch removal: [in clinic on [date/time] / at home per instructions]
• First reading: [date/time] (approximately 48 hours post-application)
• Delayed reading: [date/time / Day 4–5 / Day 7 if indicated / not scheduled]

(If appointments not yet scheduled, document plan and responsible party.)

Signature

[Electronic signature: clinician name, credentials, date/time]

(Required elements before finalizing: clinician name, date/time, consent documentation, total number of tests applied as integer, and authenticated signature. This note documents application only—do not include patch test interpretation.)