It’s summer season and both allergists and primary care physicians may be busy treating allergy symptoms caused by pollen, mold or insect stings. With allergy skin test, they can identify the exact allergen that causes the symptoms and decide on the treatment that controls the symptoms effectively. However, unless they are accurately documenting the allergic conditions and other details of each patient, the protective measures can bring adverse effects on patients rather than relief. Let’s see how accurate documentation is important for physicians treating summer allergies.
According to experts, symptoms of summer allergies can be easily mistaken for colds, food intolerances or other ailments. If the allergic conditions are not described correctly or the test results are documented wrongly, physicians may not be clear regarding whether the patient symptoms are related to summer allergy or some other cause. The need for accurate records is important when prescribing medications to the patients as well. The selection of appropriate medications and their dosage depends upon patient-specific clinical information including factors such as age, weight, allergies, diagnosis and laboratory values. If this kind of information is not sufficiently available or inaccurate, medication errors may happen which will result in poor patient care, loss of revenue or even lawsuits.
Allergy immunotherapy or allergy shots are considered as an effective option, if medications and other protective measures fail. Studies have shown that it helps cut down the total healthcare costs and prescription costs in children with allergic rhinitis or hay fever. Though this therapy is safe, the potential for an adverse reaction is always there. This therapy is not recommended for patients having medical conditions that reduce their ability to endure systemic allergic reactions (for example, chronic lung disease). This is also not recommended for patients who would have difficulty in reporting signs and symptoms of a systemic reaction (for example, children less than three or four years). Unless the history or consultation reports document this kind of information accurately, the physician may wrongly recommend this option and result in poor patient outcomes. It is required to assess patients during each injection to find out newly acquired risks that may not have been present at the beginning of the therapy, which should be documented as well for better care provision.
Electronic health records (EHRs) provide an easy and effective way to document all the information related to allergies and streamline physician workflow. However, a disadvantage is that there is more chance for making inadvertent errors such as missing information, wrong information and duplication while copy-pasting lots of information at a single stretch to save time. Moreover, the pre-defined templates limit the narrative description. Transcribing physician dictations with the help of transcriptionists and populating EHR fields with appropriate information through discrete readable transcription (DRT) technology is a more effective option.