Allergies: recording and reconciliation
Manage patient allergies and perform medication reconciliation.
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- allergiesmedicationssafety
Allergy management is critical for patient safety. This article covers recording allergies, severity, reactions, and performing medication reconciliation.
Recording allergies
Go to the patient chart → Allergies → Add allergy. Search for the allergen (medication, food, environmental). Select the reaction (hives, anaphylaxis, rash, etc.) and severity (mild, moderate, severe). Add onset date if known. Add notes for details ("Patient reports throat swelling after penicillin in 2015").
Severity and reactions
Severity guides clinical decision making. Mild: rash, itching. Moderate: hives, swelling. Severe: anaphylaxis, difficulty breathing. Reactions are coded (SNOMED CT) for interoperability. Be specific — "rash" is more useful than "allergic reaction".
No known allergies
If the patient has no allergies, click "No known allergies" (NKA) or "No known drug allergies" (NKDA). This is an explicit statement, not an empty list. NKA status is displayed prominently and prevents the "missing allergy" alert.
Medication reconciliation
At each visit, reconcile medications and allergies. Go to Medications → Reconciliation. The system shows active meds from the chart, meds from pharmacy fill history (if available), and patient-reported meds. Mark each as "Continue", "Discontinue", or "Modify". For allergies, confirm the list is accurate. Reconciliation is required for transitions of care and is a quality measure.
Allergy alerts
When prescribing, the system checks allergies and shows alerts for cross-reactivity. For example, a penicillin allergy triggers an alert for amoxicillin. Alerts show severity and reaction. You can override with a reason ("Patient tolerates cephalosporins despite penicillin allergy — per allergist"). Overrides are audited.
Allergy vs intolerance
Use "Allergy" for immune-mediated reactions (hives, anaphylaxis). Use "Intolerance" for side effects (nausea, diarrhea). Intolerances are recorded in the same list but flagged differently. Both trigger alerts, but intolerances are lower priority.