Documentation of possible drug allergy
Documenting new suspected drug allergic reactions
When a person presents with suspected drug allergy, document their reaction in a structured approach that includes:
- the generic and proprietary name of the drug or drugs suspected to have caused the reaction, including the strength and formulation
- a description of the reaction
- the indication for the drug being taken (if there is no clinical diagnosis, describe the illness)
- the date and time of the reaction
- the number of doses taken or number of days on the drug before onset of the reaction
- the route of administration
- which drugs or drug classes to avoid in future
Reference:
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