Documenting allergies in computer programs

This can easily become a contentious issue, although it doesn't really need to be. There are those nurses who will adamantly declare that charting a reaction as an allergy is diagnosing a medical condition and therefore out of our scope. When we revamped our allergy charting a few years ago we ran it by our BON, which had absolutely no problem with nurses documenting allergies, their response was that it's not only acceptable, but expected that nurses understand how to recognize a potentially allergic reaction. They also pointed out that there is a misunderstanding about a nurses scope in that nurses aren't actually prohibited from recognizing or charting conditions consistent with a medical diagnosis, nurses frequently chart what a patient's rhythm is, even though that is technically a medical diagnosis.

Even so, we got a lot of resistance from nurses, so we ended up with a charting system that combines allergies and intolerances so that nurses don't have to decide which category it falls into, they just document the medication and the reaction. A patient might have a self-reported history of throat swelling or hives after taking penicillin, or they might self-report that they become drowsy with opiate pain meds. It should be pretty obvious which one is an allergy, but this way nurses don't have to decide which is which.

That is crazy. Why wouldn't any medical provider be able to enter an allergy?? I would keep your writeen notice short and sweet. Summerize the policy and make it understandable to the average Joe.

meh

you are right as you proved with your research.

your job is not to diagnose but simply to document allergies or interlerances so that the patient is not harmed by the actions of your colleagues and peers.

intentional failure of an RN to document such contraindications in the record is extremely unprofessional.

So a new pt says they're allergic to PCN because it caused her throat to swell--that can't be documented as a drug allergy? I've never heard of a nurse not being allowed to document a drug allergy. I even document a drug allergy when there's an unknown reaction (mom said they had a rash as a child after taking drug x). True, most pts don't know the difference between an intolerance and an allergy and side effects (rapid heart beat with epi for example) but we document what the pt reports to us as an allergy. Even if it's an intolerance, especially p.o. meds, the pt won't be compliant if there's an intolerable side effect. They might not be allergic to drug x but if it causes GI upset, they're not going to take it.

Yep, this is a nonsensical opinion. Though I am not an attorney and don't play one on TV, I am pretty darn sure that if it ever came to court, the nurse who was aware of an allergy and didn't communicate it to other members of the care team in the record would be found to be in violation of standards of care for documentation.

Some people want to get caught up in the semantics of allergy vs. intolerance.

Don't go there.

The bottom line is that the chart should reflect ANY and ALL medications that the patient should not be given for any reason. This is for the patient's protection AND for yours.

For instance, I cannot take Phenergan without having a very very unpleasant physical response to the drug. It is listed (by a nurse) on all of my medical records as an allergy because no one, under any circumstances, should give me that drug; even though it is not actually an allergy.

Semantics and legalistic people give me a headache.

That is part of our admission assessment.

We aren't able to actually put it in the electronic chart, but we do send an order to pharmacy stating the pts allergy and reaction. It's just not accessible on our end of the program to put it in ourselves.

We aren't able to actually put it in the electronic chart, but we do send an order to pharmacy stating the pts allergy and reaction. It's just not accessible on our end of the program to put it in ourselves.

Do you document that you did so notify the pharmacy? If you haven't been, you should start, in case there's a problem and phcy says, "The nurse didn't tell us."

We write it as an actual order to pharmacy in the patient's chart. We are 90% electronic but some orders are still handwritten, like this one.