Best Practices for Documenting Allergies
The more information providers learn from patients, the better prepared they will be for an event
March 1, 2021 3 minutes read
A good quality improvement (QI) project for 2021 would be to focus on bolstering the way the organization handles patients’ allergy histories.
Leaders must remember that poor documentation in this area can lead to problems that place patients at risk. Accreditation Association for Ambulatory Health Care (AAAHC) explains best practice tips on how to improve documentation of patient allergies:
• Create accurate allergy record. “It’s important to have an accurate record of the patient’s allergy history,” says Belle Lerner, MA, director of research at the AAAHC Institute for Quality Improvement.
“Consistently discuss allergies with patients on each visit and properly record existing or new allergies and reactions,” she says. “As the COVID-19 pandemic continues, it’s especially important to have these conversations with patients so you can differentiate between the patient having an allergy vs. a COVID-19 symptom.”
It also is important to remember that patients do not always know about their medication allergies until something happens. For example, Lerner recalls a time when she received an antibiotic for an infection. Her body immediately reacted to the drug, but she had not known there could be a problem.
“I left the provider, and took the drug. I was driving home, I was itching,” Lerner recalls. “I didn’t think of an allergy, but when I called my doctor’s office, they said, ‘Do not take any more of the medication.’”
Surgery centers cannot anticipate all potential allergy problems, but the more information they learn from patients, the better prepared they’ll be if something occurs.
• Provide allergy education. Educate staff about all the types of allergies, including food, latex, mold, and drugs.
“They should know what we look for, and it’s not just severe anaphylactic reactions,” Lerner explains. “They need to know what an allergic reaction looks like so they won’t just think it’s a COVID symptom.”
Staff also need to know how to handle the situation if a patient has a severe reaction.
• Be consistent in patient documentation. “If providers are not consistent and thorough, then they won’t be able to use allergy documentation for crucial allergy decision-making,” Lerner says. “List the type and severity of reaction.”
Electronic health records should include prompts that help identify the correct allergy and the correct spelling. The electronic record also could send alerts when there is a medication that could pose an allergy problem. “Organizations need to make it easy and routine to update the record each time a person is seen,” Lerner stresses. “If documentation is in a consistent place in the electronic health record, or on a paper form, then make it easier for the provider to go to that place and chart it appropriately.”
Make sure to document all prescription medications and supplements as well as over-the-counter vitamins, medications, and supplements. “Some say to bring in a bag of everything you take and let the provider go through it, and that way they won’t forget to mention anything,” Lerner says. “Doing medication reconciliation is important, and allergy documentation is a subset of medication reconciliation.”
• Standardize processes. Surgeons could require patients who receive verbal or phone medication orders to provide information about their allergies and reactions, and then repeat that information to prescribers to ensure accuracy.
There could be a prompt in the electronic record that asks patients to provide updated allergy information to their pharmacy. This could lead to less confusion when the pharmacy fills the prescription and also be a last check in the process. “You also need a standardized process to make sure updates occur if the patient’s allergies change,” Lerner says. “For example, maybe there’s an error on the form, and you need to remove allergies that are not correct.”
Electronic health records could contain readily accessible allergy documentation prompts that pop up when needed. “Prescription order forms with allergy prompts can also [alleviate] prescriber issues,” Lerner says.
Finally, surgery staff should share all allergy documentation and information with the primary care provider and the pharmacy. When patients fill the prescription, pharmacists can review all allergy precautions with them one more time. “Transition in care leads to better continuity of care,” Lerner explains. “If medications are ordered in the surgery center, then make sure continuity of care remains when the patient goes back to the primary care provider.”
A good quality improvement project for 2021 would be to focus on bolstering the way the organization handles patients’ allergy histories.
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