What goes into my patient’s record?
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Maintaining accurate allergy records
Accurate documentation and communication of your patient’s penicillin allergy status to other health professionals is essential to ensure they get the right treatment. Failure to clearly record assessment outcomes in electronic health records can result in patients unnecessarily avoiding first-line antibiotics, leading to delayed effectiveness of treatment and poorer health outcomes. All health professionals should therefore ensure their patient’s allergy status is clearly documented in their medical record and uploaded to My Health Record.
It is also important that you communicate effectively with your patients the importance of confirming their penicillin allergy, that they understand what is involved in the assessment, and they understand what the result of the assessment means for them. Some patients will be resistant to letting go of their penicillin allergy label. Therefore, it is important to communicate the benefits of being assessed and the risks of hanging on to an unconfirmed penicillin allergy.
GPs should be the main point of contact for coordinating a patient’s allergy information
GPs should be the main point of contact for coordinating a patient’s allergy information, ensuring their allergy status is accurately documented in the electronic record (including My Health Record) and giving the patient a copy of their results. Other health professionals involved in the patient’s care should contribute relevant allergy information and ensure it is communicated to the GP and the patient.
For patients that have been confirmed as not allergic to penicillin, it is recommended that:
‘Penicillin allergy’ is removed from all medical records (including My Health Record) and updated with “confirmed not allergic” for penicillin.
Recorded information includes the following:
Method of confirmation, which may include:
Clinical evaluation/history
Skin test results
Challenge results
Dates of assessments
Name of health professional who completed the assessment.
There is appropriate documentation and communication with the patient and between health services to prevent reacquisition of “penicillin allergy” to their medical record.
Instructions to remove “penicillin allergy” from the patient’s medical record should be relayed to hospital systems, outpatient clinics, general practice, pharmacies and all other relevant health practices.
'Penicillin allergy' is removed from physical medical identification (such as medical alert bracelets).
An alert should be activated in the electronic health record alerting clinicians of the removal of penicillin allergy label.
The patient and relevant family members are given written documentation (such as a wallet card/letter) indicating that they are no longer penicillin allergic and at no higher risk of developing allergic reactions to penicillins than the general population.
For patients that have been confirmed as allergic to penicillin, it is recommended that:
Treat the reaction.
The patient’s penicillin allergy is clearly documented with information regarding this provided to the treating doctors and other health professionals through the internal hospital record, My Health Record, specialist referral and physical medical identification (such as medical alert bracelets).
Recorded information includes the following:
Method of confirmation, which may include:
Clinical evaluation/history
Skin test results
Challenge results
Dates of assessments
Name of health professional who completed the assessment.
Patients who react to the penicillin challenge in the community should have this appropriately documented and counseled to avoid penicillins and cephalosporins until reviewed by a drug allergy specialist.
High-risk group patients are told to avoid penicillins and cephalosporins until reviewed by a specialist.
For further information on documenting and managing allergy information on electronic health records, refer to the Best practice guidelines for the recording, transfer and access of allergy information on electronic health records which you can access by clicking on the image below.
Other helpful information
For further information on documenting and managing allergy information on electronic health records, refer to the Best practice guidelines for the recording, transfer and access of allergy information on electronic health records which you can access by clicking on the image below.
