Date:Feb2011Version2.

4February2011

Allergiesandadversereactions

RACGPStandardsforgeneralpractices(4thedition),criterion1.7.2:healthsummaries:

Ourpracticeincorporateshealthsummariesintoactivepatienthealthrecords.Healthsummariesassistinproviding
ongoingcare,bothwithinthepracticeandonreferraltootherhealthcareproviders.

Scope
Thiselementcombinesallergiesandadversedrugreactionsintooneelement.Thiselementnowincludesallergiesand
adversereactionstoallsubstances,andnotjusttomedications/medicines.Anallergyisdefinedasahypersensitive
disorderoftheimmunesystem.
1
Thiscouldincludefoodallergies,insectstingallergies,aswellasprescriptionandnon
prescriptionmedicines.

Rationale
Sixtypercentofadversereactionstomedicationscanbeprevented.
2
Theincidenceofsuchcanbegreatlyreducedby
accuraterecordingofcurrentallergyandadversereactionsstatus.Almostalleffectivedrugsnomatterhowskillfully
usedcancauseadverseeffectsinsomepatients.
3

Information captured
Thefollowinginformationshouldbecapturedwhenpossible(assupportedbythesoftware):
dateofentry/update/review
substance/agentwhereeverpossibleusingavailablecodesformedicines.Thiscouldbeadrugclass(e.g.beta
blocker,betalactam),genericnameortradename
descriptionofthereactione.g.rashoranaphylaxis(codeabletextisaflexibledatatypetosupportvarious
waysofholdingtextbothfreeandcoded)
ifreactiontodescriptionnotknownthenrecordreactionnotknown
dateofoccurrence(toberecordedas//oryearonlyataminimum)
recordutilisingthefunctionalityofthesoftware:knownallergy;unknownallergy;notasked.

Principles
Itisimportanttocaptureallreactionsthatwouldinfluencetreatmentorclinicaldecisionsduringtheprovisionof
qualityandsafecare.

Whenusinganelectronicprescribingsystem,itisimportanttocapturethereactionsviaacodedentrywherepossible
suchthatthefuturepatientcareisconsistentlysafeandofahighquality.Codingisaneffectivemeanstoaddressissues
ofhavingconsistentmedicalterminology.Itispreferableforgeneralpracticestousenationallyrecognisedcoding
systemsratherthanasystemthatisidiosyncratic.

Itisimportanttorecordnoknownallergiesandnottousethisasthedefaultintheabsenceofrecordeddata.Where
thereistheavailableclinicalsoftwarefunctionrecordeither:knownallergy;unknownallergy;ornotasked.

Date:Feb2011Version2.0
Apatientsallergyandadversereactionstatusshouldalsobereviewedatthepointofprescribinganynew
medicines/medicationsoratperiodichealthreviews.

Sharingofinformation
Level1:Wheninformationisrequiredforpatientmanagementandisonlytobesharedamongstthepracticeclinical
team.Atthislevelthekeyimplicationisthatthereisaneedforconsistentrecordingoftheinformationbyeachofthe
clinicians.Thisisimportanttoensurethatcarecanbeinitiatedthroughthefunctionalityandthedecisionsupport
availablefromtheclinicalpracticesoftware.AllinformationcomponentsoftheGPhealthsummarybuildacomplete
medicalandsocialprofiletoensurecontinuityofcareandimprovethequalityandsafetyofhealthcare.

Level2:Wheninformationistobesharedwithanotherclinicianoutsideofthepractice,suchaspointtopoint
referral(specialistreferral,thegeneralprinciplesassociatedwithappropriatereferralswouldapply.Thisincludesthe
inclusionofinformationthatisclinicallyandsociallyrelevanttothereferralandimprovesthecontinuityofcare.

Level3:Wheninformationistobesharedacrossthehealthsectorwithoneormoreproviders.Theinformation
capturedusinglocalcodesshouldbemappedtoSNOMEDwherepossible.

Resources
1. RACGPStandardsforgeneralpractices(4
th
edition)
2. AustralianCommissiononSafetyandQualityinHealthcare(ACSQHC)

References
1. Dorland,Newman.Dorlandsillustratedmedicaldictionary31
st
edition.Philadelphia:ElsevierSaunders;2009.
2. WorldHealthOrganisation.Medicines:safetyofmedicinesadversedrugreactions.FactsheetNo.293.
[October2008;cited20105thAugust];availablefrom:
www.who.int/mediacentre/factsheets/fs293/en/print.html
3. Bochner,Felix&Rossi,Simone&RoyalAustralasianCollegeofGeneralPractitioners&PharmaceuticalSociety
ofAustralia&AustralasianSocietyofClinicalandExperimentalPharmacologistsandToxicologists2007,AMH
2007:AustralianmedicineshandbookAustralianMedicinesHandbook,Adelaide.