Allergy New Patient Consult Note Template (Rhinitis, Testing and Plan)

The short answer: an allergy new patient consult note has five parts.

The referral and chief complaint say who sent the patient and what they

want answered. The history records symptoms, timing, triggers and

exposures, plus what has already been tried. The classification puts

the problem into categories that change treatment: allergic or nonallergic,

how severe, how often, and in what pattern. The testing section records

what you tested, and why the history justified it. And the plan answers

the referral question in a form the referring clinician can use.

The history carries the most weight. In the AAAAI/ACAAI Rhinitis 2020

practice parameter, the section on vasomotor rhinitis says "the history is

the most important determinant leading to diagnosis", and that skin prick

tests and specific IgE are "helpful only to exclude allergic rhinitis" in

that setting (Dykewicz MS, et al. J Allergy Clin Immunol 2020). A new

patient note that records the history well also explains your testing

choices.

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

and clinical judgment come first.

Template 1: referral, chief complaint and history

```

ALLERGY NEW PATIENT CONSULT

Referral

• Referred by: [name, specialty] / self-referred
• Question to answer: [e.g. "Is this allergic rhinitis? Candidate for

immunotherapy?"]

Chief complaint: [in the patient's words]

History of present illness

• Main symptoms: [congestion / rhinorrhea (anterior, posterior) / sneezing /

itching: nose, eyes, palate / cough / ocular symptoms / smell loss]

• Onset: [age or date]; course since: [better / worse / unchanged]
• Timing: [days per week]; [weeks per year]; [seasonal: which months /

year-round / episodic with a specific exposure]

• Triggers: [pollen season / dust / pets: which / mold / work exposures /

smoke, odors, cold air, temperature change / foods: which, and what happens]

• Impact: [sleep / work or school / daily activities / leisure]: [none /

troublesome: describe]

• Treatment tried: [drug, dose, how long, how often, response, side effects]
• Antihistamines last taken: [date/time] (for testing today)

Related history

• Asthma: [yes / no]; control: [ ]
• Eyes, sinuses, ears: [allergic conjunctivitis / sinus infections / polyps]
• Skin: [eczema / urticaria / contact reactions]
• Food reactions: [none / food, symptoms, timing, treatment]
• Drug allergies: [drug, reaction, when]
• Insect sting reactions: [none / insect, reaction, when]

Environment and exposures

• Home: [pets / carpet / visible mold / water damage / smoke exposure]
• Work or school: [occupation; symptoms better on days off? yes / no]

Medications, past history, family and social history

• Current medications: [include beta-blockers and ACE inhibitors]
• Family history of atopy: [asthma / allergic rhinitis / eczema / food allergy]
• Smoking or vaping: [ ]

```

Two fields here are skipped most often and matter most. The first is

timing. The practice parameter notes that the seasonal/perennial

classification is independent of the intermittent/persistent one: in one

population of 6,000 patients with allergic rhinitis, 55% of those with

seasonal symptoms and 45% of those with perennial symptoms had intermittent

disease. So record both the season and the days per week. The second is

impact. Severity in the parameter turns on whether symptoms interfere

with quality of life, so write down which parts of life they affect, not

just "moderate".

Record food reactions with the details of what happened. The parameter says

that outside of oral allergy syndrome, "there is no indication to test for

food allergens when evaluating patients presenting with symptoms of

rhinitis", and warns that testing with a "panel" of foods without attention

to the history "can result in mismanagement". A note that says "no

reactions to foods" explains why no food testing was ordered.

Template 2: examination and classification

```

EXAMINATION (medically appropriate)

• Vitals: [ ]
• Eyes: [injection / tearing / allergic shiners / normal]
• Nose: [mucosa: pale / boggy / erythematous / normal]; [turbinates ];

[septum ]; [polyps: yes / no]; [discharge ]

• Throat: [cobblestoning / postnasal drainage / normal]
• Ears: [ ]
• Chest: [wheeze / clear]
• Skin: [eczema / dermatographism / normal]
• Spirometry, if done: [values, interpretation]

CLASSIFICATION

• Working diagnosis: [allergic / nonallergic / mixed rhinitis / other: ]
• Severity: [mild: no interference with quality of life /

moderate-severe: troublesome, or affects sleep, work or school, daily or

leisure activities]

• Frequency: [intermittent: <4 days/week or <4 consecutive weeks/year /

persistent: >4 days/week and >4 consecutive weeks/year]

• Pattern: [seasonal / perennial / episodic environmental exposure]
• Mimics considered: [infectious rhinitis / rhinosinusitis / structural /

drug-induced / other: ]

```

The severity and frequency definitions above are the ones the parameter

uses. Mild rhinitis means symptoms don't interfere with quality of life,

such as daily activities, work or school, leisure and sleep.

Moderate/severe means symptoms are troublesome or affect any of these.

Intermittent means fewer than 4 days a week or fewer than 4 consecutive

weeks a year, and persistent means more than both. The parameter also

points out the limits of that strict cutoff: a patient with symptoms three

days a week all year would count as "intermittent".

The parameter lists the conditions that overlap with rhinitis, including

rhinosinusitis with or without nasal polyps, structural factors such as a

deviated septum, and cerebrospinal fluid rhinorrhea. It says recognizing

which one the patient has "is important because management will differ".

Write "mimics considered" even when the answer is "none likely".

Template 3: testing

```

TESTING

• Indication: [what the history suggests, and what result would change the

plan]

• Not tested, and why: [e.g. foods: no history of food reactions]
• Medications held: antihistamines since [date/time]

Skin prick testing

• Panel: [aeroallergens by region and history]
• Controls: histamine [ ] mm; saline [ ] mm
• Results: [allergen: wheal mm / flare mm] ...
• Read at: [ ] minutes; interpretation per practice criteria

Intradermal (if done): [allergens, results]

Specific IgE (if ordered instead of, or in addition to, skin testing): [ ]

Interpretation

• Sensitizations that match the history: [ ]
• Sensitizations that don't match the history: [ ] (sensitization is not

the same as clinical allergy)

```

Keep the "matches the history" line. The parameter makes the point about

foods directly, that "sensitization does not equate to clinical allergy",

and the same habit, testing what the history suggests and reading results

against it, makes the whole testing section easier to defend. For the

details of recording the panel itself, see our

skin test documentation checklist.

Template 4: assessment, plan and the letter back

```

ASSESSMENT

1. [e.g. Allergic rhinitis due to pollen, seasonal, moderate-severe,

intermittent] [ICD-10 for clinician review]

1. [e.g. Allergic conjunctivitis] [ ]
2. [e.g. Asthma, mild persistent: control status] [ ]

PLAN

• Avoidance: [specific to the sensitizations that match the history]
• Medications: [drug, dose, when to start relative to the season]
• Immunotherapy: [discussed / not a candidate now: reason / to start: route]
• Asthma: [action plan given / spirometry follow-up]
• Patient instructions: [given in writing]
• Follow-up: [interval, and what will be reassessed]

LETTER TO REFERRING CLINICIAN

• Answer to the referral question: [one or two sentences]
• Key results: [ ]
• Plan and who does what: [ ]

```

The parameter's classification by pattern maps straight onto ICD-10: it

gives J30.2 for seasonal allergic rhinitis (J30.1 for pollen), J30.89 and

J30.9 for perennial allergic rhinitis, and J30.81 for allergic rhinitis due

to animal hair and dander. If the history and the classification are in the

note, coding follows from them. Our

allergy ICD-10 coding guide

has the full list.

On billing level: since 2021, history and exam for office and outpatient

visits (99202–99215) are documented "as medically appropriate" and are "not

used in code selection". The level is chosen by medical decision making or

by total time on the date of the visit, and "time spent separately by

clinical staff is not included" (Noridian Medicare, Evaluation and

Management). So a long history doesn't raise the level by itself. A clear

assessment and plan supports the decision making, and a time statement

supports a time-based level.

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. It has visit templates built for

allergy, including new patient, follow-up, skin testing, immunotherapy and

asthma.

• It suggests ICD-10 codes from the note, and it drafts patient instructions

from the visit. The clinician reviews both.

• Evidence Mapping links lines in the review of systems and in the past,

family and social history back to the moment in the visit where they were

said. On a new patient visit, where most of the note is history, the

clinician can check where a line came from before signing.

• Patient Intelligence keeps a structured allergen profile for each

patient (medications, foods and environmental allergens) that builds

across visits, so the second visit starts from what the first one

documented.

• Skin testing (investigational): Medora drafts the panel from the

nurse's photos; clinicians confirm every value; the allergist signs. Not

FDA-cleared. Because the modules share one patient context, the clinician

can see the recorded results alongside the drafted note.

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

the diagnosis, what to test or how to treat.

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 allergy new patient note include?

The reason for referral, a history of symptoms with timing, triggers,

exposures and treatment tried, related conditions (asthma, eyes, sinuses,

skin, food, drug and insect reactions), a focused exam, a classification

(allergic or nonallergic, severity, frequency, pattern), the testing done

and why, and an assessment and plan that answers the referral question.

How is allergic rhinitis severity classified?

In the Rhinitis 2020 practice parameter, mild means symptoms don't

interfere with quality of life (daily activities, work or school, leisure,

sleep), and moderate/severe means symptoms are troublesome or affect any of

those. Frequency is classified separately as intermittent or persistent.

Should food allergy testing be part of a rhinitis workup?

The Rhinitis 2020 practice parameter says that, outside of oral allergy

syndrome, there is no indication to test for food allergens when evaluating

patients presenting with rhinitis symptoms, and that panel testing without

attention to the history can result in mismanagement.

Does a longer history raise the E/M level?

Not by itself. Since 2021, history and exam for office visits are documented

as medically appropriate and are not used in code selection. The level is

based on medical decision making or total time on the date of the visit.

Does Medora diagnose or decide what to test?

No. Medora Copilot drafts the visit note for the clinician to review, edit

and sign. Diagnosis, testing and treatment decisions stay with the

clinician.

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 immunotherapy visit note template
• The penicillin allergy evaluation note template

*Sources: Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: a

practice parameter update. J Allergy Clin Immunol. 2020;146(4):721-767

(doi:10.1016/j.jaci.2020.07.007); manuscript read via ACAAI,

https://college.acaai.org/sites/default/files/Resources/rhinitis_2020-a_practice_parameter_update.pdf.

Noridian Medicare JE Part B, Evaluation and Management (E/M),

https://med.noridianmedicare.com/web/jeb/specialties/em. Quotes are from

these sources. Check the full practice parameter, current CPT guidance and

your own payer rules.*