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Chronic Urticaria Visit Note Template (UAS7, UCT, Triggers and the Treatment Step)

2026-10-20 · 9 min read

By Pankaj Sabharwal · Co-founder, Medora

Chronic Urticaria Visit Note Template (UAS7, UCT, Triggers and the Treatment Step)

The short answer: a chronic urticaria visit note needs six things.

It needs the subtype: spontaneous, inducible, or both. It needs

disease activity as a number, usually the UAS7. It needs **disease

control**, usually the Urticaria Control Test (UCT), and a separate line

for angioedema. It records triggers and what was ruled out, and

it ends with the treatment step: what the patient takes now, at what

dose, since when, and what happens next if control isn't reached.

Scores matter more here than in most allergy visits. Chronic urticaria

comes and goes, and the patient's description on a good week can sound

very different from a bad one. A UAS7 and a UCT, recorded the same way at

every visit, let the next clinician see the trend without rereading the

history. The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline

describes urticaria as a "mast cell-driven disease that presents with

wheals, angioedema, or both" (Zuberbier T, et al. Allergy

2022;77:734-766). The template below keeps those two pieces separate.

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

approach, and current guidelines, come first.

Template 1: subtype and history

```

CHRONIC URTICARIA: HISTORY

Duration

Wheals and/or angioedema since: [date]; > 6 weeks: [yes / no]
Pattern: [daily / most days / intermittent]

Subtype

Spontaneous (CSU): [yes / no]
Inducible (CIndU): [none / dermographism / cold / heat / pressure /

cholinergic / contact / other: ]

Both: [yes / no]

Wheals

Typical duration of a single wheal: [< 24 h / > 24 h]
Distribution: [ ]; residual bruising or pigment: [yes / no]

Angioedema

Episodes: [none / yes: sites, frequency, last episode]
Throat or tongue involvement, or breathing difficulty: [no / yes: describe]
Angioedema without wheals: [yes / no]

Possible triggers and modifiers

NSAIDs or aspirin: [no / yes: which, and the effect]
Other medications started before onset: [ ]
Physical triggers reported: [scratching / cold / heat / pressure / exercise]
Patient's own suspected triggers: [ ]

Relevant history

Thyroid disease: [ ]; other autoimmune disease: [ ]
Previous treatment and response: [ ]
Sleep, work or school affected: [ ]

```

The definitions are simple and worth writing down. A review in *Clinical

& Experimental Allergy* defines chronic urticaria as urticaria "that

persists for longer than 6 weeks", and CSU as "the spontaneous appearance

of wheals with or without angioedema that persist for ≥6 weeks" (Ferrer

M, et al. Clin Exp Allergy 2015;45:731-743). The same review calls

NSAIDs "the only recognized trigger for CSU", so ask about them and

record the answer either way.

Record the inducible subtype separately even when the patient also has

CSU. It changes what you test and, since October 2026, which treatment

labels fit: remibrutinib (Rhapsido) is now indicated for adults with symptomatic

dermographism inadequately controlled by H1 antihistamines, in addition

to its earlier CSU indication (Novartis press release, October 7, 2026).

A note that says only "chronic hives" doesn't show which label applies.

Template 2: activity, control and impact

```

DISEASE ACTIVITY AND CONTROL

UAS7 (patient diary, last 7 days)

Daily wheal score 0-3 + daily itch score 0-3, summed over 7 days
UAS7 today: [ ] / 42
Diary complete: [7 of 7 days / [n] of 7 days / not kept]
Previous UAS7: [ ] on [date]

UCT (last 4 weeks)

Score: [ ] / 16
Well controlled (12 or more): [yes / no]
Previous UCT: [ ] on [date]

Angioedema

Episodes since last visit: [ ]
Activity or control score used, if any: [AAS / AECT / none]: [ ]

Impact

Quality-of-life measure, if used: [CU-Q2oL / other / none]: [ ]
Days of work or school missed: [ ]; sleep disturbed: [ ]

Exam

Wheals present today: [yes / no]; angioedema present today: [yes / no]
Dermographism on exam: [yes / no / not tested]

```

The UAS7 is the activity number. Ferrer and colleagues explain that the

number of wheals and the intensity of itch "are scored individually for

the past 24 h using a 3-point Likert scale from 0 (no disease activity)

to 3 (intense activity)", and the weekly UAS7 is the sum over seven days,

from 0 to 42. A UAS7 of 0 is the formal definition of a complete

response: as one clinician put it, it "requires 7 consecutive days free of

both wheals and itch" (Nicole Chase, MD, ConsultantLive, March 2026).

The UCT is the control number, and it's quicker to collect in clinic. It

is a four-question patient questionnaire, each item scored 0 to 4, for a

total of 0 to 16, where higher means better control (Mak HWF, et al. *J

Allergy Clin Immunol Glob* 2024;3:100290). The original version looks back

over 4 weeks, and its developers "recommend a cutoff value of 12 points

for identifying patients with well-controlled disease" (Buttgereit T, et

al. J Allergy Clin Immunol 2023, on the 7-day UCT7). Write down which

version you used.

Two habits help. First, record whether the diary is complete: a UAS7 from

four days of entries isn't the same number. Second, put the previous score

and date next to today's, because the change is what drives the plan.

Note dermographism on exam even if it isn't the reason for the visit. It

also affects how skin-test results are read, and the next person to test

this patient will want to know.

Template 3: workup

```

WORKUP

Done (date and result)

CBC with differential: [ ]
CRP and/or ESR: [ ]
Thyroid antibodies / thyroid function: [ ]
Other, only if the history points to it: [ ]

Provocation testing for inducible urticaria (if done)

Test and method: [e.g. dermographism test, cold stimulation]
Result: [positive / negative]; threshold, if measured: [ ]

Not done, and why: [e.g. no features in the history to suggest it]

```

Keep this section short on purpose. The minimal workup listed by Ferrer

and colleagues is the history and exam, the UAS and an angioedema

activity score, a quality-of-life assessment, tests to rule out physical

urticaria, a blood count, thyroid antibodies and function, and ESR and

CRP. A skin biopsy or skin prick test is done only if indicated. They add

that "unless suggested by the clinical history, there is no need to

perform extensive tests when examining a CSU patient." A "not done, and

why" line is useful to a payer or a second opinion months later.

Template 4: treatment step and plan

```

TREATMENT

Current regimen

H1 antihistamine: [drug], [dose], [times daily]
Dose relative to the standard dose: [1x / 2x / 3x / 4x]; since: [date]
Taken regularly or as needed: [regular / as needed]
Add-on therapy: [none / drug, dose, start date, number of doses so far]
Short steroid courses since last visit: [none / dates, reason]
Side effects reported: [ ]

Assessment

[CSU / CIndU: type / both], [well controlled / not controlled]

(UAS7 [ ], UCT [ ])

Change since last visit: [better / same / worse]

Plan

Treatment change: [none / increase / add / step down: details]
Reason: [one line, tied to the scores]
Diary: continue UAS7 for the 7 days before the next visit
Patient told: [when to use epinephrine, if prescribed / when to go to

the ED for throat swelling or trouble breathing]

Follow-up: [weeks]

CODES (for clinician review)

[e.g. L50.1 Idiopathic urticaria / L50.3 Dermatographic urticaria /

T78.3XXA Angioneurotic edema, initial encounter]

```

Most chronic urticaria treatment is stepwise, and the note should show

where the patient is on the steps. Ferrer and colleagues describe regular

(not on-demand) non-sedating H1 antihistamines first, with doses increased

"up to fourfold" for some patients, and omalizumab "once patients are

shown to be refractory to antihistamines". They don't recommend long-term

systemic corticosteroids. That's why "dose relative to standard" and

"since" are separate fields: whether a step has been given a fair trial

depends on both.

Write the reason for any change in terms of the scores ("UCT 6, UAS7 24

on fourfold dosing for 4 weeks") rather than "not better". It also gives

anyone reviewing a prior authorization the numbers they'll ask for.

For coding, the

allergy ICD-10 coding guide

covers the urticaria and angioedema codes. L50.1 needs a documented lack

of an identified trigger, and L50.3 needs the dermographism documented.

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 and follow-up visits.

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 history and review of systems

back to the moment in the visit where they were said. So when the note

says "no NSAID use", the clinician can check where that came from before

signing.

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

the UAS7 or UCT for the patient, and it doesn't decide the treatment

step. Those stay with the clinician and the patient's own diary.

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 a chronic urticaria follow-up note include?

The subtype (spontaneous, inducible or both), today's UAS7 and UCT with the

previous scores, angioedema episodes since the last visit, any new

triggers, the current regimen with dose and start date, and the plan with

the reason for any change. Recording the scores the same way each time is

what makes the trend visible.

How is the UAS7 scored?

The patient scores wheals and itch once a day, each from 0 to 3, for seven

days. The UAS7 is the weekly sum, from 0 to 42. A UAS7 of 0 means seven

days without wheals or itch.

What UCT score means well-controlled urticaria?

The UCT has four questions, scored 0 to 4 each, for a total of 0 to 16.

The developers recommend a cutoff of 12 points for well-controlled

disease. Higher scores mean better control.

Is remibrutinib indicated for dermographism?

Yes. Since October 7, 2026, remibrutinib (Rhapsido) has been indicated in the US for

adults with symptomatic dermographism inadequately controlled by H1

antihistamines, per Novartis. It was already indicated for chronic

spontaneous urticaria. Check the full prescribing information.

Does Medora score the UAS7 for the patient?

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

and sign. The patient's diary provides the scores, and the clinician

decides the treatment.

Try it on your own visits

*Sources: Zuberbier T, Abdul Latiff AH, Abuzakouk M, et al. The

international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the

definition, classification, diagnosis, and management of urticaria.

Allergy. 2022;77(3):734-766 (doi:10.1111/all.15090; abstract). Ferrer M,

Bartra J, Giménez-Arnau A, et al. Management of urticaria: not too

complicated, not too simple. Clin Exp Allergy. 2015;45(4):731-743

(doi:10.1111/cea.12465). Mak HWF, Lee E, Wong JCY, et al. Validity,

reliability, and sensitivity to change of the traditional Chinese

Urticaria Control Test (UCT) in Hong Kong. J Allergy Clin Immunol Glob.

2024;3(3):100290 (doi:10.1016/j.jacig.2024.100290). Buttgereit T,

Salameh P, Sydorenko O, et al. The 7-day recall period version of the

Urticaria Control Test (UCT7). J Allergy Clin Immunol. 2023

(doi:10.1016/j.jaci.2023.03.034; abstract). Novartis media release,

October 7, 2026: Rhapsido (remibrutinib) US indication expanded to symptomatic

dermographism. Chase N, Hawkes J. Treatment goals, disease control

targets and the role of patient-reported outcome measures. ConsultantLive,

March 12, 2026. Quotes are from these sources. Check the full guideline

and prescribing information, and follow your own protocols.*