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Anaphylaxis Follow-Up Visit Note Template for Allergy Practices (History, Tryptase, Epinephrine Plan and Risk Factors)

2026-10-23 · 9 min read

By Pankaj Sabharwal · Co-founder, Medora

Anaphylaxis Follow-Up Visit Note Template for Allergy Practices (History, Tryptase, Epinephrine Plan and Risk Factors)

The short answer: the note after an anaphylactic reaction needs five

things. It needs the reaction history: the suspected trigger, the

timing, the organ systems involved, the cofactors and what treated it. It

records the tryptase levels, acute and baseline, with the times they

were drawn. It documents the epinephrine autoinjector plan: how many,

which dose, and the counseling given. It reviews **medications and risk

factors** such as beta-blockers, ACE inhibitors and mast cell disease. And

it ends with the work-up and follow-up still to come.

These visits are where documentation drifts into "anaphylaxis, EpiPen

given, avoid trigger". That line can't tell the next clinician whether

the reaction was biphasic, whether a second dose was needed, or whether

the patient was taught when to call 911. The structure below follows

Anaphylaxis: A 2023 practice parameter update from the AAAAI/ACAAI

Joint Task Force on Practice Parameters (Golden DBK, Wang J, Waserman S,

et al. Ann Allergy Asthma Immunol 2024;132:124-76). Quotes are from

that document, and the recommendation numbers refer to its Table 3.

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

approach, and the full parameter, come first.

Template 1: the reaction history

```

INDEX REACTION

Date and setting: [home / school / work / restaurant / travel /

health care / perioperative]

Suspected trigger: [food / drug / insect sting / AIT injection /

exercise / unknown]

Exposure to onset: [minutes]
Organ systems: [skin / respiratory / cardiovascular / GI / other]
Hypotension or syncope: [yes / no]
Urticaria present: [yes / no]
Cofactors: [exercise / alcohol / NSAID / viral illness / menses /

stress / none]

TREATMENT AND COURSE

Epinephrine: [yes / no]; doses: [ ]; time to first dose: [ ]
Who gave it: [self / caregiver / EMS / ED]
EMS called: [yes / no]
ED visit or admission: [ ]
Pattern: [uniphasic / biphasic / protracted / refractory]

PRIOR REACTIONS

Number and dates: [ ]
Same trigger: [yes / no / unknown]

```

The parameter is direct about what the diagnosis rests on: "Diagnosing

anaphylaxis relies on a thorough clinical history that includes patient

characteristics (eg, age, sex, medical and atopic history, concurrent

medications), detailed description of the reaction (possible triggers,

symptom pattern, timing of onset duration of symptoms), concomitant

factors (eg, exercise, viral infection, medications, menstrual status,

stress, food, alcohol), and response to treatment."

Two lines in this template are easy to skip and worth keeping. The

pattern line matters because "Biphasic anaphylaxis is associated with

greater severity of the initial reaction, and requirement of more than

one dose of epinephrine to treat the initial symptoms." And the

epinephrine line should not be read as the diagnosis. Recommendation 7

suggests "that neither the clinical decision to administer epinephrine

nor the clinical response to epinephrine be used as a surrogate marker to

establish a diagnosis of anaphylaxis." Record what happened, then the

clinician's assessment separately.

Template 2: tryptase

```

TRYPTASE

Acute tryptase: [value] ng/mL, drawn [time] ([hours] after onset)
Baseline tryptase (bST): [value] ng/mL, drawn [date]
Acute rise meets 20% + 2 ng/mL above baseline: [yes / no / not

calculable]

bST measured because: [recurrent / idiopathic / severe / hypotension /

severe sting reaction / suspected mastocytosis / not indicated]

bST above 8 ng/mL: [yes / no]; HαT evaluation considered: [ ]

```

The parameter's recommendations turn straight into these lines:

Recommendation 2: "We suggest drawing an acute-phase tryptase level as

early as possible during a suspected anaphylactic event (ideally within

2 hours after onset of symptoms). We suggest drawing a second tryptase

measurement at a later time as a baseline for comparison to determine

whether there was a significant acute elevation."

The comparison itself: "an acute serum tryptase level at least 20% plus

2 ng/mL above the patient's bST level may provide evidence of systemic

mast cell activation."

Recommendation 1: "We recommend obtaining a bST in patients presenting

with a history of recurrent, idiopathic, or severe anaphylaxis,

particularly those presenting with hypotension."

Recommendation 3: "We suggest clinicians consider evaluation for HαT in

patients with elevated bST level (8 ng/mL or greater)."

A normal acute tryptase does not close the question. The parameter notes

that "many cases of anaphylaxis may not be associated with a tryptase

elevation above that level", which is why the 20% + 2 rule needs the

baseline value written next to the acute one.

Template 3: the epinephrine autoinjector plan

```

EPINEPHRINE AUTOINJECTOR (EAI)

Prescribed: [yes / no]; shared decision documented: [ ]
Dose: [0.1 mg / 0.15 mg / 0.3 mg]; weight today: [kg]
Number of devices: [1 / 2 or more]; reason: [prior multiple doses /

biphasic history / other]

Risk factors for needing EAI reviewed: [ ]

COUNSELING

When to use: at the first sign of suspected anaphylaxis
Not pre-emptively when asymptomatic
When to call EMS: severe reaction, not resolving promptly or

completely, returns or worsens after the first dose

Trainer device practiced in clinic: [yes / no]
Carriage and storage reviewed: [yes / no]
Barriers to carrying (cost, size, access): [ ]
School or childcare plan: [ ]
Medical identification discussed: [ ]

```

Each counseling line maps to a recommendation:

Recommendation 25: "We suggest that clinicians counsel patients and

caregivers to give epinephrine at the first sign of suspected

anaphylaxis. We suggest that, in general, clinicians counsel patients

or caregivers to not give epinephrine preemptively to an asymptomatic

patient."

Recommendation 26 says immediate EMS activation "may not be required if

the patient experiences prompt, complete, and durable response to

treatment with epinephrine", provided that additional epinephrine and

medical care are readily available. It also suggests counseling

patients "to always activate EMS after epinephrine use if anaphylaxis

is severe, fails to resolve promptly, fails to resolve completely or

nearly completely, or returns or worsens after a first dose of

epinephrine."

Recommendation 24 suggests routinely prescribing "more than one EAI when

patients have previously required multiple doses of epinephrine to

treat an episode of anaphylaxis and/or have a history of biphasic

reactions." That is why the template asks for the reason behind the

number of devices.

Recommendation 30: "During visits with patients who have been

prescribed EAIs, we recommend that clinicians routinely review the

essentials of EAI carriage, storage, and use; encourage patients to

regularly practice EAI administration with a trainer device; and

discuss strategies to manage barriers to adherence that patients may

have experienced."

For infants and toddlers, recommendation 12 suggests "either the 0.1 mg or

the 0.15 mg EAI dose for infants/toddlers weighing less than 15 kg", so

write today's weight on the same line as the dose.

Template 4: medications and risk factors

```

MEDICATIONS REVIEWED

Beta-blocker: [none / drug; indication]
ACE inhibitor: [none / drug; indication]
Decision: [continue / change with prescriber / not applicable];

shared decision documented: [ ]

Allergen immunotherapy or VIT: [not on / build-up / maintenance]

RISK FACTORS

Severe food allergy: [ ]
Mastocytosis or MCAS suspected: [ ]
Recurrent idiopathic anaphylaxis: [ ]
Cardiovascular disease: [ ]
Asthma: [none / yes: control today]
Possible tick bites (alpha-gal): [ ]

```

The parameter moved away from treating these medicines as automatic

contraindications. Its summary says "For most medical indications, the

risk of stopping or changing beta-blocker or angiotensin-converting

enzyme inhibitor medication may exceed the risk of more severe

anaphylaxis if the medication is continued, especially in patients with

insect sting anaphylaxis." Recommendation 33 suggests that "in most

cases, treatment with BB or ACEI medication need not be changed or

discontinued in patients receiving maintenance VIT." Recommendation 37

adds that patients at significant risk for recurrent and unexpected

anaphylaxis, such as those with severe food allergy, mastocytosis or

MCAS, or recurrent idiopathic anaphylaxis, should be counseled about the

risk "and consider avoiding, where possible, the use of nonselective BBs

or ACEIs." Either way, the decision and the discussion belong in the

note.

The alpha-gal line is there because recommendation 5 suggests clinicians

"consider alpha-gal allergy as a possible cause of recurrent IA in a

patient with history of possible tick bite."

Template 5: work-up, plan and follow-up

```

ASSESSMENT

Anaphylaxis, [trigger / idiopathic], [uniphasic / biphasic /

protracted / refractory], [date]

PLAN

Testing: [skin testing / specific IgE / challenge / not yet]
Timing of testing: [ ]
Mastocytosis evaluation considered: [yes / no; reason]
Avoidance counseling: [specific steps]
Venom immunotherapy discussed (sting reactions): [ ]
Letter or plan for school, work or surgery team: [ ]
Follow-up: [interval]

```

For a perioperative reaction, recommendation 44 suggests "that immediate

hypersensitivity testing to suspected culprit (and alternative) agents be

delayed after POA, unless repeat surgery cannot be postponed." The body

of the parameter says delaying it "for 4 to 6 weeks after anaphylaxis is

generally recommended". Writing the planned testing date in the note

keeps that from being lost.

For sting reactions, recommendation 41 suggests clinicians "consider

evaluation for mastocytosis, including a bone marrow biopsy, for adult

patients with severe insect sting anaphylaxis or recurrent IA,

particularly those with a predictive REMA score." If the reaction was to

an immunotherapy injection, the

immunotherapy visit note template

covers the dose and the build-up record. If a food was the trigger and a

challenge is planned, the

oral food challenge note template

covers that visit, and the

allergy ICD-10 coding guide

has the codes.

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 hypotension" or "no

urticaria" 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, and the clinician reviews them before the patient takes them

home.

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 "lips swelled within ten minutes" 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

diagnose anaphylaxis, doesn't interpret tryptase and doesn't decide on

epinephrine or medications. 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 anaphylaxis follow-up note include?

The reaction history (trigger, timing, organ systems, cofactors and the

treatment given, including how many epinephrine doses), the acute and

baseline tryptase with the times they were drawn, the epinephrine

autoinjector plan and the counseling given, a review of beta-blockers,

ACE inhibitors and other risk factors, and the work-up and follow-up

still planned.

When should tryptase be drawn after anaphylaxis?

The 2023 practice parameter suggests drawing an acute tryptase as early as

possible, ideally within 2 hours after symptoms start, and a second level

later as a baseline. An acute level at least 20% plus 2 ng/mL above the

baseline may provide evidence of systemic mast cell activation.

Does giving epinephrine confirm the diagnosis of anaphylaxis?

No. The parameter suggests that neither the decision to give epinephrine

nor the response to it be used as a surrogate marker for the diagnosis.

Document the treatment and the clinician's assessment separately.

When should more than one epinephrine autoinjector be prescribed?

The parameter suggests routinely prescribing more than one when a patient

has previously needed multiple doses of epinephrine for an episode of

anaphylaxis or has a history of biphasic reactions.

Who makes the diagnosis 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

*Source: Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: A 2023

practice parameter update. Ann Allergy Asthma Immunol. 2024;132(2):124-76.

doi:10.1016/j.anai.2023.09.015 (read at

https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Allergist%20Resources/Statements%20and%20Practice%20Parameters/Anaphylaxis-Practice-Paramaters-2023.pdf).

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

information, and follow your own protocols.*