Adverse Reaction Documentation

Ensuring documentation of a patient’s adverse reactions to medication, immunization, dietary, supplement and environmental exposures is a minimum use expectation. Managing this documentation involves validating prior reactions, characterizing current reactions and removing disproven reactions.

Consistent use of standardized descriptors ensures that decision supports (e.g., alerts, reminders) have few false positives and negatives.

Entering, editing and reviewing adverse reactions is done in the “allergy/contraindications” activity, which can be accessed through the Patient Storyboard in all clinical information system (CIS) contexts. Serious adverse drug reactions must be supplemented with an Adverse Drug Reaction Report when first documented.