Adverse Reaction (Allergy) Documentation Norms

What is it?

Reconciling allergy, adverse reaction, intolerance and contraindication documentation involves validating prior reactions, characterizing current reactions, adding clinically important new reactions and removing disproven reactions.

The Connect Care clinical information system (CIS) provides an "Allergy/Contraindication" activity to facilitate this work. The naming is unfortunate, as it implies limitation to formal allergic-type reactions. In fact, the activity is designed to document any clinically important adverse reaction, including medication and non-medication exposures.

Adverse reactions are prominently displayed in the Patient Storyboard, visible to all clinicians for all encounter types, and are a core attribute of the patient record.

Why does it matter?

Ensuring documentation of a patient’s adverse reactions to medication, immunization, dietary, supplement and environmental exposures is a minimum use expectation. Broad awareness helps to avoid harms when medications, dressings, supplements and topicals are considered for use. This information is routinely pulled into clinical reports, such as admission, discharge and transition summaries. Many decision supports, including checks during medication ordering, depend upon accurate adverse reaction data.

All clinicians need to trust warnings about exposures that could harm patients. If the majority of clinicians enter and ratify this information, alerts are usually meaningful, and the time required of any one clinician to find or review reactions decreases.

Consistent use of standardized descriptors ensures that decision supports (e.g., alerts, reminders) have few false positives and negatives. Consistency also facilitates quick review, finding the same descriptors in the same locations used in the same way.

Who is responsible?

Patients are responsible for forthright reports of past reactions. Healthcare providers are responsible for characterizing the type, severity and likelihood of a reaction. Nursing, allied health and clinical support staff are able to enter (document) adverse reaction information in the chart, often taking this opportunity to clarify what patients report.

Adverse reaction reconciliation, especially validating clinically important adverse reactions, is a prescriber responsibility.

Prescribers are expected to know how to use standardized descriptors when checking the completeness, precision and accuracy of reaction reports. Clinicians are also responsible, as a matter of professional standards and legislation, for adding, editing or reconciling adverse reaction information imported from other systems.

How is it done?

Entering, editing and reviewing adverse reactions is done in the “Allergy/Contraindications” activity, which can be accessed through the Patient Storyboard. Serious adverse drug reactions must be reported using a "Serious Adverse Drug Reaction" form when first documented.