Penicillin Allergy Delabeling Visit Note

Date/Time: [Date and time of encounter]

Location: [clinic / inpatient consult / perioperative clinic / other]

Author: [Author name and credentials]

Referring Clinician: [Name and referral question] (Include only if applicable.)

Sources of History: [patient / caregiver / outside records / interpreter] (Specify interpreter language if used; note reliability if history is remote or uncertain.)

Reason for Visit

Penicillin allergy evaluation/delabeling — [Immediate clinical driver] (One line only; do not expand the reaction narrative here.)

Allergy/Reaction History

[Brief narrative summary of the labeled penicillin allergy and reason for presentation] (State what is known vs uncertain; for ambiguous descriptors, include direct patient quotes and translate to clinical terms. Do not infer phenotype when history is unreliable.)

• Index Drug: [Specific agent (penicillin V / amoxicillin / ampicillin / penicillin—unknown type)], [route], [dose], [indication at the time] (State "unknown" for unavailable details.)
• Reaction Description:
  • Skin: [Findings or unknown]
  • Respiratory: [Findings or unknown]
  • Cardiovascular: [Findings or unknown]
  • GI: [Findings or unknown]
  • Mucosal: [Findings or unknown]
  • Severity markers: [hypotension / respiratory compromise / mucosal involvement / blistering / none / unknown]
  • Treatment required: [none / outpatient treatment / ED visit / epinephrine / hospitalization / unknown]
• Timing: [Time from dose to onset (minutes/hours/days)], [Day of therapy when reaction occurred], [Years since index reaction]
• Re-exposure History: [Subsequent tolerance or reactions to penicillins or other beta-lactams, with drug name and approximate timeframe]
• Relevant Comorbidities: Beta-blocker use: [present / absent / unknown]; Asthma: [well-controlled / partly controlled / poorly controlled / none / unknown]; Cardiovascular disease: [present / absent / unknown]; Mast cell disorder: [present / absent / unknown]; Pregnancy: [yes / no / unknown]

Current Allergy List Review

• EHR beta-lactam entries: [Ingredient/class, recorded reaction, severity label, date noted for each entry]
• Discrepancies: [Differences between documented allergy list and today's history, or "none identified"]
• Medication holds for testing: [Antihistamines, tricyclics, H2 blockers—status of holds and timing] (Include only if skin testing planned.)

Risk Stratification and Testing Decision

• Phenotype classification: [immediate-type / delayed benign rash / severe cutaneous or systemic pattern / unclear]
• Risk category: [low risk / moderate risk / high risk] (Low: benign symptoms, nonurticarial rash, vague/unknown, remote history. Moderate: urticaria or suggestive symptoms without anaphylaxis, unclear timing. High: anaphylaxis features, severe reaction history.)
• Contraindications today: [present / absent] (If present, specify: SCAR history, unstable comorbidity, inability to observe appropriately, or other.)
• Chosen pathway and rationale: [Direct oral amoxicillin challenge without skin testing / Penicillin skin testing followed by oral challenge if negative / Defer testing with plan / Avoid penicillin indefinitely or refer for specialist evaluation] — [Rationale based on history and risk]
• Shared decision-making: Risks discussed: [immediate reaction, possible delayed rash]; Benefits: [label removal, antibiotic access]; Alternatives: [avoidance, non–beta-lactam options, referral]; Patient questions addressed: [yes / no]; Agreement to proceed: [yes / no]; Written consent obtained: [yes / no / not required per protocol]

Objective

Baseline vitals: [Vitals]

Focused exam: General: [Appearance]; Skin: [Findings]; Respiratory: [Findings]; Cardiovascular: [Findings]

Penicillin Skin Testing

(Include this section only if skin testing was performed.)

Indication: Evaluation of reported penicillin allergy for potential delabeling.

Reagents: [List each reagent and concentration, including positive and negative controls]

Method: [Prick/puncture and/or intradermal per protocol]; Sites: [Anatomical location]; Marking: [Method]

Timing: Start: [Time]; Read: [Time(s)]; Interval: [Duration]

Results:

Reagent/Control	Method	Wheal (mm)	Flare (mm)	Interpretation
[Reagent/control name]	[prick / intradermal]	[mm]	[mm]	[negative / positive / equivocal]

Adverse Events: [None / Description with treatments given including drug, dose, route, time]

Interpretation: [Negative / Positive / Equivocal] — [Implications for next steps]

Oral Amoxicillin Challenge

(Include this section only if an oral challenge was performed.)

Pre-test Risk Category: [Low / Moderate / High]

Drug Administered: [Amoxicillin formulation], [Dose(s)], [Route]

Protocol: [Single-step (full dose) / Graded—specify steps and amounts]

Timeline: Dose(s): [Time and amount for each]; Observation: [Start time] to [End time]; Total observation duration: [Duration after final dose]

Monitoring: Pre-dose: [Vitals and symptom check]; Interval: [Assessments per protocol]; End of observation: [Final assessment]

Outcome: [Tolerated without symptoms (pass) / Objective reaction occurred (fail)—specify phenotype / Indeterminate or incomplete—specify reason]

Delayed Reaction Counseling: Patient counseled on signs requiring contact (rash, fever, mucosal lesions) and how/when to reach clinic or seek urgent care: [Yes / No]

Adverse Reaction During Challenge

(Include this subsection only if a reaction occurred during the challenge.)

• Onset: [Time from last dose to symptom onset]
• Findings by system: Skin: [Findings]; Respiratory: [Findings]; Cardiovascular: [Findings]; GI: [Findings]; Mucosal: [Findings]
• Treatments given: [Drug, dose, route, time for each intervention]
• Response and disposition: [Clinical response]; [Observation duration]; [Final disposition]

Results Summary and Interpretation

[Bottom-line statement of what was performed today and the clinical interpretation] (For negative workup: "Penicillin skin testing was negative and patient tolerated observed oral amoxicillin challenge. Findings support removal of penicillin allergy label. Patient may receive penicillins in the future as clinically indicated." For positive result/reaction: "Patient developed [objective findings] during observed amoxicillin challenge requiring treatment; this supports continued amoxicillin allergy labeling. Avoid amoxicillin and related agents per plan below." For deferred/indeterminate: state current status and rationale.)

Assessment and Plan

Reported penicillin allergy—evaluation today: [Delabeled (disproved) / Confirmed (positive testing or reaction) / Not fully evaluated (deferred/indeterminate)]

• Acceptable antibiotics: [Specify which beta-lactams may now be used, or state continued avoidance]
• Antibiotics to avoid: [Specify agents to avoid, if any]
• Follow-up needs: [Referral, repeat testing, desensitization evaluation, or none] (Include only if applicable.)
• Communication to PCP: [Planned method and timing]

[Additional relevant problems] (Include only if directly relevant to allergy risk or testing, e.g., asthma management, pregnancy-related antibiotic planning.)

EHR Allergy List Update

• Action Taken: [Deleted/inactivated penicillin allergy entry / Modified reaction details / Reclassified as intolerance or adverse effect / No change] — Evidence: [e.g., "Tolerated observed oral amoxicillin challenge on (DATE). Penicillin allergy disproved."]
• Allergy list updated in EHR today: [Yes / No] (If no, document reason and who will complete the update.)
• Patient Education: Patient informed of: current allergy status [yes / no]; what to report to other clinicians and pharmacies [yes / no]; need to update personal medical records or medical alert information [yes / no]

Follow-up and Communication

• PCP/Referring clinician notified: [Yes—method / No—reason]
• Inpatient team notification: [Primary team, ID, or stewardship pharmacist notified—yes/no and names] (Include only for inpatient encounters.)
• Surgical/Anesthesia notification: [Method and recipient] (Include only for perioperative evaluations.)

(If procedures were not performed, document in Assessment and Plan why testing/challenge was deferred and the specific follow-up plan. Use explicit "unknown" or "unavailable" for missing historical elements rather than leaving blanks.)