Allergies documented
Formal Definition
"Allergies documented" — a standard section of the H&P and ongoing notes documenting (1) drugs the patient is allergic to (with reaction type and severity), (2) foods (with reaction type, especially important for peanut/tree nut, shellfish, milk, egg, soy, wheat), (3) environmental (latex, seasonal pollens, pet dander), and (4) contrast/implant reactions; updated on every encounter as part of the medication reconciliation and pre-procedure checklist; an essential patient-safety module in every major EHR and required documentation element for billing, Joint Commission compliance, and medicolegal protection.
How It's Used on the Ward
"Updating allergies" or "verify allergy list" — what nurses and providers do on every admission, transfer, and medication reconciliation; allergies module is one of the most error-prone modules in EHRs with frequent oversimplification ("NKDA") or erroneous food entries that patients later remember differently.
Example
""Admission H&P for 58-year-old woman with NSTEMI: Allergies: 'Penicillin — rash (childhood); patient reports mother told her she had a rash as a baby after amoxicillin; not anaphylaxis; no exposure since. Shellfish — throat swelling (twice; ER visit; unclear if related to iodine content vs shellfish protein). Latex — contact dermatitis. NKDA otherwise. NKFA (no known food allergies) beyond shellfish above.' Cardiology reviewing the pre-cath checklist: notes penicillin allergy and consults the institutional protocol for cath-prep antibiotic selection in penicillin-allergic patients (cefazolin if not severe, vancomycin if severe). Patient counseled: shellfish is not iodine allergy, but contrast media still safe in shellfish allergy; patient tolerated cath without reaction.""
Clinical Context
Standard allergy documentation elements: substance, reaction type (anaphylaxis, angioedema, urticaria, rash, GI, etc.), severity (fatal, ED visit, hospital admission, mild), date or age of last reaction, currently on therapy (some "allergies" are current active symptoms, like a chronic urticaria). Specific food allergy documentation: latex (associated with banana, kiwi, avocado, chestnut cross-reactivity), peanut (severe, lifelong; risk of anaphylaxis), shellfish (separate from iodine), tree nuts, sesame (newer FDA-labeled allergen). Distinguishing intolerance from allergy: nausea from metformin is intolerance (patient doesn't like the drug; not immune-mediated); hives and angioedema from penicillin are allergy. Documentation timing: every encounter, not just initial — patients may recall reactions that were not initially disclosed. EHR best practice: standardized reaction-type pick-lists (Free-text allergies are a documented source of medication errors); ability to flag severity (so e-prescribing system can warn at order entry). Cross-checking: allergies module is a required review before ordering any new medication, before anesthesia induction, before IV contrast administration.