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Allergy Documentation Guidelines

written by: CoDayDreamer • edited by: Diana Cooper • updated: 10/27/2010

Medical professionals use guidelines to keep patients safe. Learn about allergy documentation guidelines and how they help protect the patient.

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    Importance of Documenting Allergies

    Allergy documentation guidelines are essential to patient safety in a hospital and clinic setting. The introduction of medication, environmental or food allergens to a patient can have harmful effects on the health and recovery of the patient.

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    Patient Bracelets

    In a hospital setting, patient's are identified by patient bracelets. There is a bracelet with their identifying information such as name, patient number and date of birth. Patient's with allergies are identified with an additional bracelet that is red. The purpose of the bracelet is not to state what the allergen is but to quickly visually alert medical professionals that there is an allergy. The bracelet is placed on the patient on admission to the hospital and removed by the patient after discharge. When a patient is wearing an allergy bracelet, jewelry and social cause bracelets should be removed to avoid confusion.

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    Chart Stickers

    Chart stickers are a form of alerting medical professionals that there is a condition that needs attention when interacting with a patient. There are chart stickers for smoking cessation, infectious diseases and allergens. The sticker is placed on the front of a patient's chart. To ensure that medical professionals immediately identify the sticker the color is red and it is placed in a predominate place. The sticker will state what the patient is allergic to.

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    Benefits

    A benefit of documenting allergies is that medical professionals will recognize allergens by patient bracelets, chart stickers and computer programs that notify them of patient allergies. This will reduce the number of errors that result in further illness or morbidity.

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    Risks

    Allergy documentation guidelines outline procedures intended to keep patients safe, but there is still the risk of human error. For medication allergies, very often a medication may contain another medication that the patient is allergic to. If the medical professional is not aware of the medication contents, even with the patient's allergen documented, it is possible for an allergen to be given to the patient. By using an electronic system to verify the compatibility of medications to patient's with allergies this risk can be reduced and/or eliminated. Computer systems can also reduce the risk of error by seamlessly updating information throughout the patient's medical record. As an example, if a patient record states an allergen in the admission documentation, it can be updated automatically in the nurses notes and discharge documentation.

    Another risk is that the allergy bracelet may not be visible if it becomes covered by clothing. If a medical professional verifies allergens exclusively by the presence or lack of an allergy bracelet the patient may be exposed to an allergen. To reduce this risk, medical professionals should always verify allergies by reviewing the paper or electronic charting system prior to administering any medication. When the patient is transferred to another department or medical center, the allergies should be verified through the charting system and not the allergy bracelet to reduce the risk of error. At this time, there is not a standard that requires all hospitals and medical centers to have the bracelet system.

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    References

    St. Vincent's Hospital: Latex and How It Effects the Hospital - http://www.ciap.health.nsw.gov.au/hospolic/stvincents/stvin99/Andrea.htm

    Oregon Association of Hospital and Health Systems: Color-coded Wristband Standardization in Oregon - http://www.oahhs.org/quality/initiatives/file-library/wristband_faqs.pdf