AI Scribe for Allergy & Immunology
Transcribe Health drafts your consult, testing, and follow-up notes while you work, so the panel results and the immunotherapy plan are on the page before you leave the room.
Photo: Towfiqu barbhuiya / Unsplash
Allergy documentation, from first panel to maintenance
A new allergy consult is a lot of moving parts in one visit. You take an environmental and food history, decide what to test, run a skin prick panel or order specific IgE, and then read a grid of results antigen by antigen. Each positive needs its wheal and flare measurement against the histamine and saline controls, and the whole thing only means something next to the history you just took. Getting that into a note by hand, in order, without transposing a number, is slow work.
Immunotherapy visits are short but easy to document wrong. A patient comes in for an injection, you check the vial and dilution, give the scheduled dose, watch for 30 minutes, and record any reaction. Miss a detail and the next escalation is built on a bad record. Over a full build-up and into maintenance that is dozens of small, precise entries per patient.
Then there is the long tail: asthma follow-ups with spirometry, chronic rhinitis, chronic urticaria, and food-allergy management with anaphylaxis action plans. These run for years. Transcribe Health listens to the visit and drafts a note that puts the detail where it belongs: the panel results, the FEV1 and FVC, the drug names and doses, and the reasoning behind your plan. You read it and sign. Nothing is filed without you.
Documentation Challenges in Allergy & Immunology
- 1
Recording skin prick and intradermal panels antigen by antigen, with wheal and flare measurements, positive and negative controls, and serum specific IgE values that all have to line up with the clinical picture
- 2
Keeping immunotherapy records straight across the build-up and maintenance phases: vial contents, dilutions, dose escalations, reactions, and the schedule the patient is actually on
- 3
Tracking chronic asthma, rhinitis, and urticaria over years of follow-up, including spirometry trends, symptom scores, step-up and step-down decisions, and biologic therapy like omalizumab or dupilumab
How Transcribe Health Helps Allergy & Immunology
Testing Panel Notes
Captures each antigen you test and the result you read: wheal and flare sizes, controls, and specific IgE values, laid out so the note matches the panel.
Immunotherapy Records
Records the vial, dilution, and dose for each injection visit, along with any local or systemic reaction and the next scheduled step.
Chronic Disease Follow-Up
Documents asthma, rhinitis, and urticaria visits with the spirometry numbers, symptom history, and medication changes you discuss, including biologics.
An allergy note, captured in real time
An abridged new consult for allergic rhinitis with skin prick testing and an immunotherapy discussion, drafted the way you would see it before signing.
34-year-old woman with three years of worsening nasal congestion, clear rhinorrhea, sneezing, and itchy eyes, worse in spring and early fall. Symptoms are not controlled on daily loratadine and intermittent intranasal fluticasone. Reports mild interrupted sleep and reduced work productivity during flares. Two dogs at home, carpeted bedroom. No wheezing, no history of anaphylaxis. Denies chest tightness or nocturnal cough.
Afebrile, comfortable, no acute distress. Nasal mucosa pale and boggy with clear secretions, no polyps seen. Conjunctivae mildly injected. Chest clear. Percutaneous skin prick testing to a 24-antigen aeroallergen panel performed on the volar forearm. Histamine control 6 mm wheal, saline control 0 mm. Positive results: dust mite (D. farinae) 8 mm wheal with 20 mm flare, timothy grass 7 mm wheal, ragweed 6 mm wheal, dog dander 5 mm wheal. Negative to cat, cockroach, and tested mold mixes.
1) Allergic rhinitis (J30.1 seasonal, J30.2 other seasonal), moderate persistent, with sensitization to dust mite, timothy grass, ragweed, and dog dander confirmed on skin prick testing. 2) Allergic conjunctivitis, mild. Symptoms inadequately controlled on current second-generation antihistamine plus as-needed intranasal steroid.
Step up to daily intranasal fluticasone 2 sprays each nostril and add azelastine nasal spray. Continue loratadine 10 mg daily. Reviewed environmental controls: allergen-encasing mattress and pillow covers, weekly hot-water bedding wash, HEPA filtration, and keeping dogs out of the bedroom. Discussed subcutaneous immunotherapy given the confirmed sensitization pattern and partial response to medication; patient interested. Will order specific IgE to confirm dust mite and grass before starting build-up, and schedule an immunotherapy planning visit. Prescribed and reviewed use of an epinephrine auto-injector as a precaution for the injection course. Follow up in 6 weeks.
Illustrative example. Not a real patient encounter.
Built for allergy coding and your EMR
Notes capture the antigens tested, the results you read, and the problem complexity behind your plan. That is what supports your E/M level, a clean skin-test count, and the medical necessity for immunotherapy, and it is the first thing to slip when charting is rushed.
- 99204 / 99205New-patient consult, moderate to high complexity
- 99214 / 99215Established-patient follow-up, moderate to high complexity
- 95004Percutaneous (prick/puncture) allergy skin tests, per test
- 95165Preparation of allergen immunotherapy vials, per dose
- 95115 / 95117Allergen immunotherapy injection, single or two or more
- 94010Spirometry with graphic recording
- J30.1Allergic rhinitis due to pollen
- J30.2Other seasonal allergic rhinitis
- J45.909Unspecified asthma, uncomplicated
- L50.1Idiopathic urticaria
- T78.40XAAllergy, unspecified, initial encounter
Fits the workflow you already have
Drafts drop into the major EMRs allergy practices run on: Epic, Oracle Health (Cerner), and athenahealth, plus specialty systems like Xolair-era immunotherapy modules where your group tracks vials and schedules. You get whatever note type you are working in, a new consult, a testing visit, or an injection follow-up. It writes up the panel results and spirometry numbers you dictate. It does not run the tests or read the antigen grid for you; you make the call and it records it.
Allergy & immunology AI scribe questions
Does it handle skin test panels and their results?
Can it keep immunotherapy records straight across build-up and maintenance?
Does it understand allergy terminology and drug names?
How is patient information protected?
Does it connect to our EMR?
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