Quality statement 4: Recording drug allergy status in electronic medical records

Quality statement

People with drug allergy have their status documented in their electronic medical record using the recommended coding framework.

Rationale

At present, the coding is not used consistently in electronic documentation systems to differentiate between a side effect and an allergic reaction. Consistent and comprehensive recording of drug allergy status is important to ensure that all patients with confirmed or suspected drug allergy have a full and accurate record of this in their electronic medical record. Accurate recording of drug allergy status will prevent the prescription and administration of drugs inducing allergic reactions and will improve patient safety.

Quality measures

Structure

Evidence of local arrangements to ensure that people with drug allergy have their status documented in their electronic medical record using the recommended coding framework.

Data source: Local data collection.

Process

Proportion of electronic medical records with a drug allergy status documented using the recommended coding framework.

Numerator – the number in the denominator with a drug allergy status documented using the recommended coding framework.

Denominator – the number of electronic medical records.

Data source: Local data collection.

Outcome

a) Mortality.

Data source: Local data collection.

b) Repeat allergic drug reactions.

Data source: Local data collection.

c) Length of hospital stay.

Data source: Local data collection.

d) Inappropriate avoidance of drugs.

Data source: Local data collection.

e) Anaphylaxis.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary and secondary care services) ensure that healthcare professionals document a person's drug allergy status in their electronic medical record using the recommended coding framework.

Healthcare professionals document a person's drug allergy status in their electronic medical record using the recommended coding framework.

Commissioners (NHS England area teams and clinical commissioning groups) commission services in which healthcare professionals document a person's drug allergy status in their electronic medical record using the recommended coding framework.

What the quality statement means for patients, service users and carers

People have a note in their electronic medical record of whether or not they have a drug allergy. This should be noted as 'drug allergy', 'none known' or 'unable to ascertain' (doctors aren't sure whether a reaction is due to drug allergy or not). If doctors aren't sure they should investigate further.

Source guidance

  • Drug allergy (2014) NICE guideline CG183, recommendation 1.2.1.

Definitions of terms used in this quality statement

Coding framework for drug allergy status

Use 1 from the following coding framework when documenting a person's drug allergy status in their medical records:

  • 'drug allergy'

  • 'none known'

  • 'unable to ascertain' (document it as soon as the information is available).

[Drug allergy (2014) NICE guideline CG183 recommendation 1.2.1]