Allergies and adverse reactions
If allergies and adverse reactions are not captured as structured data within your clinical information system, you may miss contraindications if you are prescribing, and important information about the severity of a reaction.
Note that under the RACGP Standards, practices must keep a record of known allergies for at least 90% of their active patient health records (Criterion QI2.1 – Health Summaries reads: “Our active patient health records contain a record of each patient’s known allergies.”) If a patient has no known allergies, a practitioner must verify this with the patient and then record ‘no known allergies’.
To improve the data on allergies and adverse reactions, you should first differentiate between the two when you enter the patient’s information in your clinical information system. Second, you should code the severity of the reaction and the nature of the reaction. You can use data extraction tools such as PEN CAT4 or POLAR to track the percentage of patients on your books without an allergy reaction recorded.