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Documentation of possible drug allergy

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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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The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

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