skin testing
Penicillin Allergy Evaluation Note Template (History, Risk, Challenge and Delabeling)
2026-10-13 · 8 min read
The short answer: a penicillin allergy evaluation note has five parts.
The reaction history records what happened, when, and what was done
about it. The risk assessment puts that history into a low- or
higher-risk group, and says why. The testing plan records whether you
skin tested, went straight to a supervised oral challenge, or did neither.
The challenge log records each dose, the time, and what you saw. And the
outcome section says what the label is now, and confirms that the
allergy list was changed to match.
That last part matters as much as the test. The 2022 drug allergy practice
parameter from the AAAAI and ACAAI gives a strong recommendation that drug
challenges, when indicated, "should be performed to remove incorrect drug
allergies from a patient's medical record, especially for penicillin or
sulfonamide allergies" (Khan DA, et al. J Allergy Clin Immunol
2022;150:1333-1393, as summarized in the JAMA Clinical Guidelines
Synopsis by Singla, Elios and Davis, 2024). A negative challenge that never
reaches the allergy list hasn't removed anything.
This is a documentation aid, not a protocol. Your practice's own drug
challenge protocol, signed off by your allergists, comes first.
Template 1: the reaction history
```
PENICILLIN ALLERGY EVALUATION: HISTORY
Label as recorded
- Drug on the label: [penicillin / amoxicillin / ampicillin / "PCN" / other]
- Where the label came from: [patient report / parent report / outside record / pharmacy]
The index reaction
- Drug and route: [e.g. oral amoxicillin]
- Indication: [e.g. otitis media]
- When: [date or age; interval since reaction: ≤5 years / >5 years / unknown]
- Onset after first dose: [minutes / hours / days]; day of course: [ ]
- Symptoms: [urticaria / morbilliform rash / angioedema / respiratory /
hypotension / GI only / headache / other]
- Skin involvement: [none / benign rash / blistering, mucosal or skin peeling]
- Duration: [ ]
- Treatment needed: [none / antihistamine / steroid / epinephrine / ED visit /
admission]
Since then
- Same or similar drug taken since? [yes: drug, date, tolerated? / no / unknown]
- Cephalosporins taken since? [yes: drug, date, tolerated? / no / unknown]
- Family history of penicillin allergy only? [yes / no]
- Relevant medications today: [antihistamines and when last taken; beta-blockers]
- Relevant conditions: [asthma control, pregnancy, current illness]
```
Two details in this section change the plan more than any other. One is the
interval: the practice parameter treats a remote history (more than five
years ago) of a mild, nonanaphylactic reaction as low risk. The other is
severity: a history of anaphylaxis or a severe cutaneous adverse reaction
such as Stevens-Johnson syndrome generally rules out a challenge. Record both
explicitly, even when the answer is "unknown". "Unknown interval" is a
category of its own in the PEN-FAST rule below.
The Cleveland Clinic Journal of Medicine review by Ohtola and Hong (2022)
lists the components essential to the history: "how long ago the reaction
occurred, symptom details, timing of symptom onset, duration of reaction" and
"use of same or similar medication since". Every field above maps to one of
those.
Template 2: the risk assessment
```
RISK ASSESSMENT
PEN-FAST (adults; patient-reported history)
- Five years or less since reaction, or unknown interval: [ ] (2 points)
- Anaphylaxis or angioedema, OR severe cutaneous reaction: [ ] (2 points)
- Treatment was required for the episode: [ ] (1 point)
- Total: [ ] / 5
Risk group: [low / moderate / high], because: [one line]
Contraindications to challenge: [none / anaphylaxis / SCAR (SJS/TEN, DRESS) /
other: ]
Not an allergy history? [e.g. GI upset or headache only; family history only]
```
PEN-FAST is a decision tool that uses the patient's own history to find
people at low risk who may be suitable for a direct oral challenge. In the
derivation study of 622 patients, a score of 0 had a negative predictive
value of 99.4%, and a score below 3 had a negative predictive value of 96.3%
(Trubiano JA, et al. JAMA Intern Med 2020;180:745-752, as reported in the
JAMA synopsis). It was built in adults, so write down when you're applying
it to a child or not using it at all.
Write the "because" line in plain words. The next clinician (or the
hospital pharmacist who sees this note in three years) needs to know why
you went straight to a challenge, or why you didn't.
Template 3: testing plan and challenge log
```
TESTING PLAN
- Approach: [direct oral challenge / skin testing, then challenge /
no testing: label removed on history / not a candidate: reason]
- Why this approach: [e.g. remote benign cutaneous reaction, PEN-FAST 0]
- Consent: [verbal documented / written signed]
- Antihistamines held since: [date/time]
SKIN TESTING (if done)
- Reagents and concentrations: [ ]
- Controls: positive [ ] mm, negative [ ] mm
- Prick results: [ ]; intradermal results: [ ]
- Read time: [ ]; interpretation per practice criteria: [positive / negative]
CHALLENGE LOG
- Drug, form, lot: [e.g. amoxicillin suspension]
- Steps: [1-step / 2-step]
Dose 1 [time] [amount, e.g. one-tenth of therapeutic dose] vitals [ ] findings [ ]
Dose 2 [time] [remaining dose] vitals [ ] findings [ ]
- Observation after last dose: [start time] to [end time]
- Reaction: [none / symptoms, time of onset, treatment given, response]
```
The synopsis describes the most common challenge shape: two steps, a test
dose (for example, one-tenth of the therapeutic dose), then the remainder
about 30 minutes later if there's no reaction, followed by 60 minutes of
monitoring. Single-dose challenges may also be considered when the risk is
low. It also notes that children with prior benign cutaneous symptoms
(such as a morbilliform rash or urticaria) from aminopenicillins don't
require skin testing before a monitored direct amoxicillin challenge (strong
recommendation, moderate certainty of evidence). Whatever your protocol
says, the log should let someone reconstruct exactly what was given and when.
Template 4: outcome and the record
```
OUTCOME
- Result: [tolerated: no reaction / reaction: describe / not done]
- Interpretation: [penicillin allergy ruled out / penicillin allergy confirmed /
indeterminate: plan]
- Delayed reactions: patient told to report rash or other symptoms over the
next [ ] days, and how
ALLERGY RECORD
- Allergy list updated: [label removed / label changed to: ] on [date] by [ ]
- Outside records to update: [PCP, pharmacy, hospital]: [sent / to send]
- Patient given: [written result / wallet card / letter]
CODES (for clinician review)
- [e.g. Z88.0 Allergy status to penicillin, only if the allergy is confirmed]
Follow-up: [none needed / as needed / other]
```
The synopsis is blunt about why the record step matters. In large
case-control studies, patients with a reported penicillin allergy were more
likely to develop vancomycin-resistant Enterococcus, *Clostridium
difficile* or MRSA, and had longer hospital stays. It also notes that the
allergy section of the electronic health record "is often inaccurate and
commonly includes nonallergic reactions", and points to an AAAAI work group
report on improving it (Guyer AC, et al. J Allergy Clin Immunol Pract
2022;10:2854-2867).
Give the patient something in writing. A label that comes off in your
office can come back the next time a different clinic asks, "Any drug
allergies?"
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. It has visit templates built for allergy, including drug and
food challenges, 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 history and review of systems back
to the moment in the visit where they were said. So when the note says
"reaction more than five years ago", the clinician can check where that
came from before signing.
- The clinician reviews, edits and signs every note. Medora doesn't decide
who is low risk, whether to challenge, or when to stop. Those stay with the
clinician and your practice's protocols.
In a 60-day pilot at Allergy Affiliates, the time an allergist spends
signing off each skin-test visit dropped sharply
Frequently asked questions
Do low-risk patients need penicillin skin testing before an oral challenge?
Not always. The 2022 AAAAI/ACAAI practice parameter says children with prior
benign cutaneous symptoms from aminopenicillins don't require skin testing
before a monitored direct amoxicillin challenge. For adults with a remote
(more than five years) history of a mild, nonanaphylactic reaction, a
monitored challenge without prior skin testing may be considered. Follow your
practice's protocol.
What is the PEN-FAST score?
PEN-FAST is a decision rule that uses the patient's history to identify
adults at low risk of a true penicillin allergy. It gives 2 points for a
reaction five years ago or less (or an unknown interval), 2 points for
anaphylaxis, angioedema or a severe cutaneous reaction, and 1 point if
treatment was required. In the derivation study, a score below 3 had a
negative predictive value of 96.3%.
How long are patients observed after a penicillin challenge?
The JAMA synopsis of the practice parameter describes the common approach
as a test dose, then the remaining dose about 30 minutes later, then 60
minutes of monitoring. Your own protocol sets the observation period.
What should the note say after a negative penicillin challenge?
That penicillin allergy was ruled out, what was given and when, that no
reaction occurred during observation, and that the allergy list was updated
on a specific date. Also record what the patient was given in writing, and
which outside records were notified.
Does Medora decide whether a patient can be delabeled?
No. Medora Copilot drafts the visit note for the clinician to review, edit
and sign. Risk assessment, the decision to challenge, and the
interpretation of the result 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 oral food challenge note template
- The allergy ICD-10 coding guide
*Sources: Singla R, Elios MC, Davis AM. Evaluation of Suspected Antibiotic
Allergies (JAMA Clinical Guidelines Synopsis). JAMA. Published online
September 11, 2024 (doi:10.1001/jama.2024.14143), summarizing Khan DA,
Banerji A, Blumenthal KG, et al. Drug allergy: a 2022 practice parameter
update. J Allergy Clin Immunol. 2022;150(6):1333-1393
(doi:10.1016/j.jaci.2022.08.028). Ohtola JA, Hong SJ. Does my patient need
an allergy evaluation for penicillin allergy? Cleve Clin J Med.
2022;89(3):126-129 (doi:10.3949/ccjm.89a.21004). Quotes are from these
sources. Check the full practice parameter and follow your own protocols.*