Quality Medical Transcription Services

Documenting Patient Allergies in the Electronic Health Record

Allergies affect more than 50 million Americans each year and are the sixth-leading cause of chronic illness in the United States. While year-round allergies are usually a reaction to food, medications, dust mites, pet dander, or mold, seasonal allergies affect people only during certain times of the year. Experts point out that allergies are getting worse year after year due to climate change.  Recent reports of the “pollen-ocalypse have raised concerns among allergy specialists. Regardless of the cause, patient allergies need to be documented properly in their electronic health record (EHR) so that they can be shared among all the health care professionals involved in their care. With the start of the allergy season, allergy and sleep medicine transcription services are a practical option for physicians to manage challenging documentation tasks.

Documenting Patient Allergies in the Electronic Health Record

 Common Allergy Triggers

 Allergies are the result of the reaction of the body’s immune system to a foreign substance or allergen, even though it is not harmful. Allergies can affect the skin, sinuses, airways or digestive system. Allergens responsible for allergic reactions include:

  • Pollen
  • Dust
  • Food
  • Insect stings
  • Animal dander
  • Mold
  • Medications/Drugs
  • Latex

Seasonal allergies or hay fever, which occur between spring and autumn, are typically caused by pollen produced by plants such as grass, trees, and weeds. Hay fever symptoms include sneezing, itching of the nose, eyes or roof of the mouth, runny or stuffy nose, and watery, red or swollen eyes.

The allergic reaction to insect stings include swelling in the area of the sting, itching or hives all over the body, cough, chest tightness, wheezing or shortness of breath, and anaphylaxis, which is a life threatening reaction.

Penicillin is the most common trigger of drug allergies. A drug allergy causes reactions similar to an insect sting as well as facial swelling. According to the Asthma and Allergy Foundation of America, drug reactions affect 10 percent of the world’s population.

Documentation of Patient Allergies in the EHR

Drug allergies are usually overdiagnosed, misdiagnosed, and self-diagnosed, according to a commentary published by the Agency for Healthcare Research and Quality (AHRQ). Patient allergies need to be documented correctly and promptly in the EHR. Up to 18% of serious, preventable adverse drug events (ADEs) occur as a result of practitioners having insufficient information about the patient before prescribing, dispensing, and administering medications (www.magmutual.com). However, a study published in Ann Allergy Asthma Immunol reported that the EHR allergy section is often handled by providers with limited drug allergy training and knowledge, resulting in missing reaction details and discrepancies with patient interview.

MagMutual cites a Pennsylvania Patient Safety Advisory report which found more than 3,800 reports of cases in which patients received medications to which they had documented allergies. The failures in communication of allergy information include:

  • Entry of patients’ allergies on paper but not in the organization’s computerized order-entry systems
  • Allergy information not consistently documented in expected locations
  • Organizations’ attempts to include all drug allergens on the wristband
  • Allergies occurring during treatment but not entered in the medical record or communicated to appropriate staff.

Incomplete and inaccurate EHR allergy entries affect future prescribing and lead to patient harm.

Best Practices for Documenting Allergies in the EHR

 Healthcare practitioners should have access to current and accurate medication information about patients when prescribing, dispensing, and administering medications. The Pennsylvania Patient Safety Advisory recommends these best practices for documenting allergy information:

  • Standardizing the current location(s) where allergy information (including patient reactions) is documented and retrieved by practitioners and staff
  • Having a process in place to ensure that the information is update if the patient’s allergies change. Providers and staff should be educated on this.
  • Including clearly visible and prominently placed allergy prompts in consistent locations on the top of every page of all prescriber order forms
  • Developing processes to check and update allergy information upon each patient encounter.
  • Making the allergy reaction selection a mandatory entry in the organization’s order-entry systems for prescribers and pharmacists.
  • Asking for patient’s allergies and reactions when communicating medication orders verbally or by telephone. The receiver of the order should always present this information to the authorized prescriber.
  • Documenting “No Known Allergies” and the date recorded if the patient reports having “no known allergies”.

The National Institute for Health and Care Excellence (NICE) states that the following information should be documented when a patient presents with a suspected drug allergy:

  • Generic and proprietary name of the drug or drugs suspected to have caused the reaction, including the strength and formulation.
  • Description of the reaction.
  • Indication for the drug being taken; the illness should be described if there is no clinical diagnosis.
  • Date and time of the reaction, number of doses taken, or number of days on the drug before onset of the reaction, and route of administration.
  • Which drugs or drug classes to avoid in the future.
  • Wherever possible, recording drug allergies separately from adverse drug reactions

The guideline also suggests taking a drug allergy history and updating this at all patient encounters and whenever a drug is prescribed, dispensed, or administered.Above all, prescribers, nurses and pharmacists should be educated about medication allergies, focusing on screening patients, recognition of an allergic reaction, and the treatment of serious allergic reactions.

The allergy season is in full swing. US based medical transcription companies specializing in sleep and allergy medicine transcription are ready to help healthcare providers ensure that allergy status is properly recorded and updated in the EHR. Partnering with a reliable service provider will allow physicians to focus on the complex task of diagnosing and treating allergies.

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