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Allergy Immunotherapy Visit Note Template (SCIT Start, Build-Up and Re-Evaluation)

2026-10-06 · 7 min read

By Pankaj Sabharwal · Co-founder, Medora

Allergy Immunotherapy Visit Note Template (SCIT Start, Build-Up and Re-Evaluation)

The short answer: an immunotherapy chart has three kinds of entries, and

each needs different things written down. The start of immunotherapy

needs the extract contents, the schedule and consent. Every injection

needs a pre-injection screen, the vial and dose, and what happened during the

wait. Every re-evaluation visit, at least every 6 to 12 months, needs

efficacy, reactions, adherence and a decision about continuing or adjusting.

The template below follows the joint task force practice parameter from

AAAAI, ACAAI and the Joint Council (*Allergen immunotherapy: a practice

parameter third update*, J Allergy Clin Immunol 2011;127:S1-55). Its Summary

Statement 91 is blunt: "The allergen immunotherapy extract contents, informed

consent for immunotherapy, and administration of extracts should be

documented," and an injection "should not be given unless adequate

documentation is available in the patient's medical record."

It's a documentation aid, not a protocol. Your practice's own dosing,

missed-dose and reaction protocols, signed off by your allergists, come

first.

Template 1: starting immunotherapy

Use this at the visit where you decide to start subcutaneous immunotherapy

(SCIT).

```

IMMUNOTHERAPY START NOTE

Indication

Diagnosis: [allergic rhinitis / allergic asthma / venom / other]
Relevant sensitizations (test type, date): [SPT / intradermal / sIgE results]
Correlation with history: [which positives match the symptoms and exposure]
Why immunotherapy: [symptoms despite avoidance and medication / patient preference / other]

Risk review

Asthma: [none / controlled / not controlled]; baseline spirometry or PEF: [value]
Beta-blockers / ACE inhibitors: [none / listed]
Pregnancy status (if applicable): [ ]
Prior systemic reactions: [ ]
Epinephrine auto-injector: [prescribed / not indicated], teaching done: [Y/N]

Prescription (extract contents)

Vial set: [name / ID]
Allergens and concentrations in the maintenance concentrate: [list]
Dilutions prepared and labeling: [v/v dilution, number/color code]
Schedule: [conventional / cluster / rush], build-up interval: [ ]
Target maintenance dose: [ ]

Consent and education

Risks discussed, incl. local and systemic reactions and delayed reactions: [Y]
30-minute wait after every injection explained: [Y]
Written consent signed: [date]
Action plan for a delayed reaction given: [Y]

Plan

First injection date: [ ]
Re-evaluation: [date, within 6-12 months]

```

Why each part is there:

Correlation with history. A positive test alone doesn't justify an

allergen in the vial. Writing which positives match the history is what

makes the extract contents defensible later.

Risk review. The practice parameter names symptomatic asthma, high

sensitivity, beta-blocker use, injections from new vials and dosing errors

as risk factors for systemic reactions.

Extract contents. If the patient moves or changes allergists, Summary

Statement 68 says the schedule and extract contents "must accompany" them.

A vague record can mean starting build-up again.

Labeling. Summary Statement 90 recommends a consistent labeling system

for dilutions. If you use a numbering system, the highest concentration is

number 1.

Template 2: each injection visit

This is the entry the nurse writes most often, so keep it short and the same

every time.

```

IMMUNOTHERAPY INJECTION

Pre-injection screen

Asthma symptoms / exacerbation since last injection: [none / describe]
PEF (if asthmatic): [value] vs personal best [value]
New medications (beta-blockers): [none / listed]
Health change, incl. pregnancy or febrile illness: [none / describe]
Reaction to last injection: [none / local size mm / systemic]
Days since last injection: [ ] -> dose adjusted per protocol: [Y/N, how]

Administration

Vial: [set / dilution / color], lot: [ ], expiry: [ ]
New vial today: [Y/N]
Dose (mL): [ ] Arm: [L/R]
Given by: [name]

Observation (30 minutes)

Wait completed: [Y / left early at __ min]
Local reaction at check: [none / mm]
Systemic symptoms: [none / describe, grade, treatment, epinephrine dose and time]

Next dose and interval: [ ]

```

What the practice parameter says about these parts:

The pre-injection screen. It "might include questions regarding the

presence of asthma symptom exacerbation, b-blocker use, change in health

status (including pregnancy), or an adverse reaction to the previous

allergen immunotherapy injection," and a peak flow for patients with

asthma.

Withholding a dose. Injections should be withheld during an acute

asthma exacerbation, and the parameter suggests considering withholding

when peak flow is low for that patient. If you hold a dose, the note

should say why.

The 30-minute wait. Patients should wait in the office "for at least

30 minutes after the immunotherapy injection," because most serious

systemic reactions start within that window. Write down if a patient left

early.

New vials and days since the last dose. These are where dose changes

happen, so the note should show the interval and any adjustment made under

your protocol.

Template 3: the re-evaluation visit

Summary Statement 23 says patients on immunotherapy "should be evaluated at

least every 6 to 12 months." It lists five reasons: to assess efficacy, to

reinforce safe administration and monitor adverse reactions, to assess

adherence, to decide whether immunotherapy can be stopped, and to decide

whether the dosing schedule or allergen content needs to change. The note

template follows those five reasons.

```

IMMUNOTHERAPY RE-EVALUATION

Status

Phase: [build-up / maintenance], months on maintenance: [ ]
Current vial set and maintenance dose: [ ]

Efficacy

Symptoms vs baseline: [ ]
Medication use vs baseline: [ ]
Asthma control (if applicable): [ ]

Safety

Local reactions since last review: [ ]
Systemic reactions since last review: [none / dates, grade, treatment]
Epinephrine auto-injector current: [Y/N]

Adherence

Missed or late injections: [ ]
Barriers: [ ]

Continue or stop

Years of treatment so far: [ ]
Decision: [continue / plan to stop / stopped], reasoning: [ ]

Adjustments

Schedule or dose change: [none / describe]
Extract content change (new mix = treat as a new extract): [none / describe]

Assessment and plan: [ ]

Next re-evaluation: [date]

```

Two details worth writing down:

The continue-or-stop decision. Summary Statement 24 says that decision

"should generally be made after the initial period of 3 to 5 years of

treatment," weighing severity, the benefit sustained and convenience.

Writing your reasoning at each review makes that later decision easier.

Changes to the extract. Summary Statement 69 says an extract "must be

considered different if there is any change." If the mix changes, the

note should say so, along with how dosing was handled.

Where these notes usually go wrong

Most of what the templates above ask for gets said out loud during the visit.

The patient mentions a new blood-pressure pill. The parent says the arm was

swollen for a day after the last shot. The patient says the spring was the

best in years. Those details are easy to miss when the note is written at the

end of the day.

Medora was built with a working allergy practice to keep them:

Medora Copilot has a visit template built for immunotherapy, alongside

templates for new patients, follow-ups, skin testing, asthma, and drug and

food challenges. It listens to the visit and drafts an allergy-structured

SOAP note with pertinent negatives.

At a follow-up, Patient Intelligence shows a snapshot of the prior visit,

so the re-evaluation starts from what was documented last time.

Evidence Mapping links each line of the note back to the part of the

conversation it came from, so the clinician can check where "local swelling

after last injection" came from before signing.

The clinician reviews, edits and signs every note. Doses, schedules and

whether to continue immunotherapy stay with the clinician.

In a 60-day pilot at Allergy Affiliates, provider sign-off per skin-test visit went from 18 minutes to 4

(the case study).

Frequently asked questions

What should be documented for each allergy shot?

At a minimum: the pre-injection screen (asthma symptoms, new medications such

as beta-blockers, health changes including pregnancy, any reaction to the

last injection, and peak flow for patients with asthma), the vial, dilution

and dose given, and the outcome of the observation period, including any

local or systemic reaction and how it was treated.

How long should patients wait after an immunotherapy injection?

The AAAAI/ACAAI practice parameter says patients should wait in the office

for at least 30 minutes after an immunotherapy injection, because most

serious systemic reactions start within that time. Patients at higher risk

may be asked to wait longer.

How often should patients on immunotherapy be re-evaluated?

At least every 6 to 12 months, according to the practice parameter, to

assess efficacy, safety and adherence, and to decide whether to continue,

stop or adjust treatment.

What records go with a patient who transfers immunotherapy care?

The schedule and extract contents, plus a record of reactions and how they

were managed, and the patient's response to treatment. Without clear

records, the new allergist may need to re-evaluate and restart.

Who sets immunotherapy doses when Medora drafts the note?

The clinician, under your practice's protocols. Medora Copilot drafts the

visit note for the clinician to review, edit and sign; dosing, schedules and

every immunotherapy decision stay with the clinician.

Try it on your own visits

*Source: Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice

parameter third update. J Allergy Clin Immunol. 2011;127(1 Suppl):S1-55

(Summary Statements 23, 24, 68, 69, 90 and 91, and the section on

pre-injection evaluation), and ACAAI's sample immunotherapy administration

instructions (college.acaai.org). Quotes are from the practice parameter.

Check for later practice parameter updates and follow your own protocols.*