Allergic Rhinitis Visit Note Template for Allergy Practices (Type, Severity, Triggers and the Treatment Plan)

The short answer: a rhinitis note needs five things. It needs the

type: allergic, nonallergic or mixed. It needs **frequency and

severity**, intermittent or persistent, mild or moderate/severe, with the

quality-of-life impact that decides severity. It records the **trigger

pattern (seasonal, perennial or episodic) next to the sensitization**

on record. It lists the comorbidities that travel with rhinitis:

asthma, conjunctivitis, rhinosinusitis and sleep. And it ends with the

treatment plan: what the patient actually uses, what changes, and why.

Rhinitis is the most common reason a patient sits in an allergy clinic,

which is exactly why its notes drift into "allergies, uncontrolled,

continue meds". That note can't tell the next visit whether the patient is

allergic or mixed, which season hurts, or why a combination spray was

added. The structure below follows *Rhinitis 2020: A practice parameter

update* from the AAAAI/ACAAI Joint Task Force on Practice Parameters

(Dykewicz MS, Wallace DV, et al. J Allergy Clin Immunol

2020;146:721-67). Quotes are from that document.

This is a documentation aid, not a treatment protocol. Your practice's own

approach, and the full parameter, come first.

Template 1: type, frequency and severity

```

RHINITIS CLASSIFICATION

Type: [allergic / nonallergic / mixed / local allergic (suspected)]

Frequency

• Days per week with symptoms: [ ]
• Consecutive weeks per year with symptoms: [ ]
• Pattern: [intermittent / persistent]

Severity

• Interferes with sleep: [yes / no]
• Interferes with work or school: [yes / no]
• Interferes with daily activities or leisure: [yes / no]
• Overall: [mild / moderate-severe]

Symptoms (0 none - 3 severe, or your practice's scale)

• Congestion: [ ] Rhinorrhea (anterior / posterior): [ ]
• Sneezing: [ ] Itching (nose / eyes / palate): [ ]
• Cough: [ ] Smell reduced: [yes / no]

```

The parameter's intermittent and persistent cut-offs are "<4 days/week or

<4 consecutive weeks/year" versus "≥4 days/week and ≥4 consecutive

weeks/year". Severity is defined by impact: mild when "symptoms are not

interfering with QOL such as impairment of daily activities, work or

school performance, leisure activities, and sleep", and moderate/severe

"when symptoms are troublesome or there is negative impact on any of these

QOL parameters". Recording the three yes/no answers, not only the label,

lets the next clinician see what changed.

Two items are easy to skip and worth the line. The 2020 update says

"Cough is emphasized as a common symptom in both AR and NAR". And a

reduced sense of smell gets its own line because the parameter notes it

can lower quality of life, including the ability to notice "spoiled food

or leaking gas".

Template 2: triggers, exposures and sensitization

```

TRIGGER PATTERN

• Seasonal: [spring / summer / fall; worst months: ]
• Perennial: [year-round; dust mite / animal / mold / cockroach]
• Episodic: [e.g. visiting a home with pets]
• Irritant triggers: [smoke / odors / cold air / temperature change /

alcohol / spicy food / exercise]

• Occupational exposure: [none / describe]

SENSITIZATION ON RECORD

• Test type and date: [skin prick / intradermal / serum-specific IgE]
• Positive to: [allergens]
• Matches the history: [yes / partly / no]
• Food allergy testing for rhinitis alone: not indicated

EXPOSURE AND MITIGATION

• Pets at home: [ ]; bedroom: [ ]
• Mitigation discussed: [none / specific steps]

```

The trigger pattern and the sensitization belong side by side. Seasonal,

perennial and episodic exposure is how the parameter classifies allergic

rhinitis by "temporal pattern of environmental exposure to a triggering

allergen", and it notes that most patients "are polysensitized to both

pollens and perennial allergens". Irritant triggers point the other way:

vasomotor rhinitis "is often activated by temperature and humidity

changes, especially cold dry air, airborne irritants, strong odors,

including tobacco smoke, and/or exercise".

The food allergy line is deliberate. The parameter's recommendation 4 is

"that food allergy testing not be performed in the routine evaluation of

possible AR". Writing it down saves a later reader from wondering whether

it was missed.

If the history is convincing but skin and serum tests are negative, note

that too. The parameter describes local allergic rhinitis as a perennial

or seasonal history after exposure with negative skin prick tests and

serum-specific IgE but a positive nasal allergen provocation test, and

says it may be present "in up to 25% of patients with rhinitis".

For the testing visit itself, the

skin test documentation checklist

covers controls, readings and sign-off.

Template 3: comorbidities

```

COMORBIDITIES REVIEWED

• Asthma: [none / yes: control today, see asthma section]
• Allergic conjunctivitis: [ ]
• Rhinosinusitis (acute / chronic, with or without polyps): [ ]
• Sleep: [trouble falling asleep / waking / not refreshed / none]
• Oral allergy symptoms with raw fruit or vegetables: [ ]
• Other: [adenoids / septal deviation / reflux / medication-related]

```

Rhinitis rarely travels alone. The parameter says allergic rhinitis "is

often associated with and can potentially impact asthma, allergic

conjunctivitis, rhinosinusitis, and sleep disturbances", and that it is

present "in about 75% to 80% of all patients with asthma". If the patient

has asthma, document it with its own control score; the

asthma follow-up note template

has that section.

Template 4: current treatment and plan

```

CURRENT REGIMEN (as the patient actually uses it)

• Intranasal corticosteroid: [drug, sprays, daily / as needed]
• Intranasal antihistamine: [ ]
• Oral antihistamine: [drug; first- or second-generation]
• Decongestant: [intranasal / oral; days in a row]
• Leukotriene receptor antagonist: [ ]
• Eye drops: [ ]
• Spray technique checked: [yes / no]
• Allergen immunotherapy: [not on / SCIT / SLIT tablet: extract, phase]

ASSESSMENT

• [type] rhinitis, [intermittent / persistent], [mild / moderate-severe],

[improved / unchanged / worse] since [date]

PLAN

• Change: [start / stop / continue], and why: [ ]
• Montelukast, if used: prior therapies tried and the response
• Intranasal decongestant, if added: stop date (no more than 4 weeks)
• Immunotherapy discussed: [yes / no; decision]
• Follow-up: [interval]

```

Several of the parameter's recommendations turn directly into a line in

the plan:

• "Intranasal corticosteroids (INCS) remain the preferred monotherapy for

persistent AR", and there is "additive benefit of combination treatment

with INCS and intranasal antihistamines in both AR and NAR". If you add

the second spray, say why.

• "Montelukast should only be used for AR if there has been an inadequate

response or intolerance to alternative therapies." The note should name

what was tried. The parameter also flags that serious neuropsychiatric

events have been reported with montelukast.

• Intranasal decongestants "generally should be limited to short-term use

to prevent rebound congestion", although patients on an INCS "may be

offered, in addition, an intranasal decongestant for up to 4 weeks".

Write the stop date.

• "Depot parenteral corticosteroids are not recommended for treatment of

AR due to potential risks", and "Oral decongestants should be avoided

during the first trimester of pregnancy".

• "SCIT and SLIT tablets are both effective for the treatment of AR and may

help prevent and/or treat allergic asthma." Record whether immunotherapy

was discussed and what the patient decided; the

immunotherapy visit note template

covers the visits after that.

For coding, the specific J30 code follows the trigger: J30.1 for pollen,

J30.2 for other seasonal, J30.81 for animal dander, J30.89 for other

allergic rhinitis such as perennial dust mite, and J30.0 for vasomotor

rhinitis. A trigger pattern and a matching sensitization in the note are

what support a specific code over J30.9. The

allergy ICD-10 coding guide

has the full list.

Where Medora fits

Medora is an AI copilot built only for allergy and immunology practices,

built with a working allergy practice, Allergy Affiliates in Bradenton,

Florida.

• Medora Copilot listens to the visit and drafts an allergy-structured

SOAP note, including pertinent negatives, so "no eye itching" or "no

night waking" makes it into the draft. It has visit templates built for

allergy, including new patient, follow-up and immunotherapy visits.

• Each assessment item in the note carries its suggested ICD-10 code, for

the clinician to review. It also drafts patient instructions from the

visit.

• Evidence Mapping links lines in the history and review of systems

back to the moment in the visit where they were said, so the clinician

can check where "worse every April" came from before signing.

• Patient Intelligence keeps a structured allergen profile for each

patient that builds across visits, and at a follow-up it shows a

snapshot of the prior visit.

• The clinician reviews, edits and signs every note. Medora doesn't

classify the patient's rhinitis and doesn't choose the treatment. Those

stay with the clinician.

In a 60-day pilot at Allergy Affiliates, the time an allergist spends

signing off each skin-test visit dropped sharply

(the case study).

Frequently asked questions

What should an allergic rhinitis note include?

The type (allergic, nonallergic or mixed), frequency (intermittent or

persistent) and severity (mild or moderate/severe, based on sleep, work or

school, and daily activities), the trigger pattern and the sensitization

on record, comorbidities such as asthma and conjunctivitis, the regimen

the patient actually uses, and the plan with the reason for any change.

What is the difference between intermittent and persistent rhinitis?

In the Rhinitis 2020 practice parameter, intermittent means fewer than 4

days a week or fewer than 4 consecutive weeks a year. Persistent means 4

or more days a week and 4 or more consecutive weeks a year. The parameter

notes the cut-offs have limits, so record the actual pattern too.

Should food allergy testing be part of a rhinitis workup?

Not routinely. The 2020 parameter recommends that food allergy testing not

be performed in the routine evaluation of possible allergic rhinitis.

When should montelukast be documented for allergic rhinitis?

The parameter says montelukast should only be used for allergic rhinitis

after an inadequate response or intolerance to alternative therapies, so

the note should name what was tried first and how the patient responded.

Who decides the rhinitis classification when Medora drafts the note?

The clinician. Medora Copilot drafts the visit note for the clinician to

review, edit and sign, and the clinician makes the assessment and every

treatment decision.

Try it on your own visits

• See how Medora handles allergy documentation
• Start the 14-day free trial of Medora Scribe (no card needed)
• Book a demo
• Read the full buyer's guide
• The allergy new patient consult note template
• The allergy ICD-10 coding guide

*Source: Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A

practice parameter update. J Allergy Clin Immunol. 2020;146(4):721-67.

doi:10.1016/j.jaci.2020.07.007 (read at

https://corporate.thermofisher.com/content/dam/allergy/clinical-resources/us/rhinitis-2020-practice-parameter-update-2020.pdf).

Quotes are from this source. Check the full parameter and prescribing

information, and follow your own protocols.*