Documenting Patient Allergies

Documenting Patient Allergies

Documenting patient allergies is not only an expectation of surveyors, it’s a critical patient safety function. How does your facility document patient allergies? Are you asking the right questions? Are they documented in a prominent and consistently defined location? Are you providing appropriate clarification of all noted allergies? This is a task we often take for granted, but doing it incorrectly could result in survey deficiencies, or worse…patient harm.

The expectation that facilities ask patients about all allergies and sensitivities and then document them clearly, is consistent across licensing and accrediting organizations such as the Centers for Medicare and Medicaid Services (CMS)Accreditation Association for Ambulatory Health Care (AAAHC), The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) and The Joint Commission (TJC). The patient’s medical record should show evidence that the patient was asked to provide information about allergies and sensitivities at each encounter and those allergies/reactions should be documented consistently and prominently.

What is an allergy?

According to AAAHC, allergies are defined as “abnormal reactions of the immune system that occur in response to allergens. An allergic reaction may occur on contact with an otherwise harmless substance or subsequent to medication administration.”

Why is allergy documentation important?

From a patient safety standpoint, improperly documenting allergies, has many potential implications. The most obvious is not documenting a medication the patient is actually allergic to. In this case the patient could receive a mediation they are allergic to potentially leading to patient harm or death. Also problematic is documenting an allergy when in reality an allergy does not exist.  In this case, it could restrict providers from using the preferred medication or even other related medications (another class that may have cross-sensitivity), out of fear of triggering a reaction. Additionally, the alternative drug that is ultimately used, may be one the patient is allergic to unbeknownst to the provider.

Investigating and documenting patient allergies:  

When a patient reports an allergy, and prior to treatment, it is imperative that a thorough history of the patient’s allergy be obtained. Some questions to consider asking include:

  • Are there any medications you cannot take for any reason?
  • Describe the reaction you had to the medication in question.
  • How long ago did the reaction occur?
  • Have you taken the same drug since? If so, what happened?
  • Have you taken a similar medication? If so, what happened?

This final question is particularly informative for patients who may report an allergy to penicillin or opioids. Have they taken a cephalosporin? How about other opioids? Although this list is not all inclusive, it’s a good starting point to determining what steps need to be taken to proceed with treatment.

Finally, the presence of allergies, sensitivities and other reactions to drugs, materials, food and environmental factors should be recorded in a prominent and consistently defined location in all clinical records. Any noted allergy should be further clarified with the specific reaction. Remember that patients often confuse adverse reactions with allergies and a reported “allergy” could actually be just a side effect that can be minimized or avoided. Finally, make sure when changes are reported, they are documented in the patient’s medical record.

We all know someone who claims to be allergic to every substance known to mankind. When it comes to treating patients, it’s important to be able to differentiate between potential side effects and actual allergies. Asking proper questions, making clear determinations, and then documenting them will go a long way to enhance the safety of each patient and has the added benefit of making surveyors happy.

We specialize in helping facilities make surveyors happy. If you have questions about documenting allergies or want to make your next survey less stressful, reach out to us…we can help.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centerssenior care facilities and pharmacies. We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.

Any health, medical or drug information on the Web Site is for informational purposes only. This information is not intended to be used, and you should not use it, as a substitute for obtaining professional healthcare advice, diagnosis or treatment. You should always seek the advice of your doctor, a pharmacist or other qualified healthcare provider for professional healthcare advice, diagnosis or treatment for any medical condition.