Allergy/Intolerance Procedure

Transcription

1 Subject/Title Approving Authority: Keith Dewar Allergy/Intolerance Procedure Classification: Patient Rights, Safety and Protection Contact for Interpretation: Documentation Coordinator - Clinical Quality and Professional Practice Source Manual: Reference Number: Effective Date: Nov 13 th, 2017 Revision Dates: See Related Policy Allergy Record refers to: Allergy/Intolerance Record (RQHR 1455) See Appendix A NOTE: The red sleeve is a red, plastic page protector placed at the front of a person s health record so that the health care team can quickly locate and identify allergy/intolerance documents. All copies of the following documents are to be stored in the red sleeve with the most current copy of each at the front of the red sleeve. Allergy/Intolerance Record (see Appendix A) Allergy/Intolerance Changes (see Appendix B) The Allergy/Intolerance Record is a permanent part of the person s health record and remains at the front of the active chart while the person is receiving care from the Regina Qu Appelle Health Region (RQHR) health care team. On discharge, the contents from the red sleeve are filed intact at the front of the discharged health record. Procedure 1. Obtain the allergy/intolerance history and document on the Allergy Record, from the following sources as applicable: Patient Family member Friend Medical Alert ( e.g. bracelet or necklace) Pharmacy resources Previous patient record Medication Administration Record (MAR) from previous facility 2. Each allergy/intolerance documented will include allergy/intolerance type and reaction details.

2 3. If the patient s allergy/intolerance history is unobtainable, document in the unable to obtain section of the Allergy Record. The allergy/intolerance status must be reviewed daily until the allergy history is verified. 4. Allergies/intolerances will be documented in Sunrise Clinical Manager (SCM) Facility Board or Procura where available. 5. The completed Allergy Record will be immediately faxed to pharmacy and allergies/intolerances will be communicated to appropriate departments. 6. The patient s allergy/intolerance history will be reviewed prior to prescribing, dispensing or administering any medications or non-medications (i.e. latex or food). Exception: In emergency situations, urgent or stat medications may be administered without a completed allergy/intolerance history. 7. Document See Allergy Record in the section(s) of all other documents in the patient s chart that have a prompt for documenting allergy information. 8. A visual cue shall be used to identify all patients with allergies/intolerances. The allergies/intolerances are not required to be written on the visual cue. Red arm bands will be the visual cue for patients where patient identification bands are utilized. Red allergy stickers will be the visual cue for patients where patient identification bands are not utilized. A red allergy sticker will be applied to the outside of the chart where the patient identification label is (either front or spine of chart). 9. The Neonatal Intensive Care Unit (NICU) will only use the Allergy Record as needed. All newborns are considered no known allergies unless proven otherwise. 10. The Mother Baby Unit (MBU) will use the Allergy Record for mothers but only as needed for newborns. All newborns are considered no known allergies unless proven otherwise. 11. Notify any other departments or units which require allergy/intolerance information: Environmental Services regarding patient allergies to cleaning substances Nutrition and Food Services regarding food allergies (SCM Facility Board) Medical Imaging regarding allergies related to contrast medium Other care providers as needed Page 2 of 5

3 12. Allergy/intolerance information shall be kept current and be retained as a permanent part of the health record. 13. If an allergy or intolerance is identified after admission: The allergy or intolerance is added to the Allergy Record. Changes are communicated to all appropriate departments. Update visual cues (if applicable). 14. If an allergy or intolerance is found to be invalid: Removal of a medication allergy/intolerance from the Allergy Record requires a physician order. Removal of a food allergy/intolerance from the Allergy Record requires a dietitian or physician order. Update the Allergy Record by drawing a single line through the incorrect allergy/intolerance, mark void, your initials and date. Document rationale for change on the Allergy/Intolerance Changes section on the back of the Allergy Record. Changes are communicated to all appropriate departments. Update visual cues (if applicable). 15. When a patient is transferred to another health care facility/service, the Allergy Record is copied and sent with the patient to the receiving care provider. 16. When the patient is discharged to the community, a copy of the Allergy Record is given to the patient with the suggestion to provide a copy of it to other health care providers (e.g. family physician, pharmacist, nurse practitioner, etc.) so that all records will remain current. 17. Upon discharge, the contents from the red sleeve are filed intact at the front of the discharged health record and the red sleeve remains on the unit for reuse. References: This procedure was adapted with permission from Saskatoon Health Region Procedure # (July, 2013). Page 3 of 5

4 Appendix A Page 4 of 5

5 Appendix B ALLERGY/INTOLERANCE CHANGES Addressograph DATE ALLERGY/INTOLERANCE RATIONALE FOR CHANGE INITIAL CHANGES MUST BE RE-FAXED TO PHARMAY AND RE-ENTERED IN SCM OR PROCURA Adapted with Permission from the Saskatoon Health Region Page 5 of 5