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Pediatric Allergy Consultation Note
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Finished note
Example — generated by Notat from a sample visit
Reason for visit: Three-day history of fever, runny nose, and reduced appetite. Drinking fluids and passing urine normally. Assessment: Likely uncomplicated viral upper respiratory infection. Child is alert and clinically stable today. Plan: Supportive care and fluid intake advised. Parent given clear safety-netting for breathing difficulty, dehydration, or persistent fever. Clinical documentation: Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.
FactsContext™
symptoms
Symptoms: Fever, runny nose, and reduced appetite for three days
history of present illness
Hydration: Drinking fluids and passing urine normally
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
assessment
Working diagnosis: Likely uncomplicated viral upper respiratory infection
plan
Safety-netting: Seek review for breathing difficulty, dehydration, or persistent fever
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
denials of symptoms
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
Template
Pediatric Allergist Note Patient Identification: [Patient name, age, gender, presenting with...] History of Present Illness: [Detailed description of allergy symptoms, onset, duration, frequency, triggers, and any associated features] [Relevant previous episodes, treatments tried, and response] [Impact on daily activities, school, and quality of life] Past Medical History: (hyphenated list) - [Chronic illnesses] - [Previous allergic conditions] - [Hospitalizations or surgeries] Medications: (hyphenated list) - [Medication name, dose, route, frequency] - [Include over-the-counter and supplements] Allergies: (hyphenated list) - [Drug allergies] - [Food allergies] - [Environmental allergies] - [Other relevant allergies] Family History: (hyphenated list) - [Family members with allergic conditions, asthma, eczema, autoimmune diseases] Social History: (hyphenated list) - [Tobacco exposure: type, amount, duration, quit date if applicable] - [Pets in home] - [Environmental exposures: mold, dust, pollen] - [School/daycare attendance] - [Living situation: who lives with patient, home environment] Physical Examination: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [General appearance] - [Skin: rashes, eczema, urticaria] - [HEENT: nasal mucosa, conjunctiva, throat] - [Respiratory: breath sounds, wheezing, stridor] - [Other relevant systems] Investigations: (hyphenated list) - [Allergy testing results: skin prick, serum IgE, specific allergen panels] - [Other relevant labs or imaging] Assessment & Plan: [One-sentence patient summary including age, sex, and primary allergic diagnosis] #) [Assessment as a numbered item] (hyphenated list with each corresponding plan item on a new line) - [Further investigations planned or ordered] - [Allergen avoidance strategies] - [Pharmacologic management: antihistamines, inhalers, epinephrine, etc.] - [Immunotherapy discussion] - [Education and counselling for patient/family] - [Referrals to other specialists if needed] - [Follow up plan] - [Return precautions]
Shared by
PN
Dr. Priya Nair
Pediatrician, Singapore
How it works in Notat
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