Allergy And Intolerance Status

modeled after a trial form at a local hospital:

Drugs (list or check box) Reaction Description Dr Sig & Printed name Date/Time Update faxed to Pharmacy
_ None Known
_
Unable to obtain
    (initials)
         
         
         
         
Latex    
_ no
_ unknown
_ yes
_ localized
_ systemic
     
Contrast Media    
_ no
_ unknown
_ yes
If yes, check test if known
_ CT
_ IVP
_ MRI
_ Other
     
Food / Other    
         
         

Reaction description:
  • Document signs and symptoms, also time of onset <24h, 24-72h, or >72h relative to drug administration
Latex:
  • Localized: rash or localized hives following direct contact with latex
  • Systemic: throat constriction, bronchospasm, low blood pressure, asthma, generalized swelling, prominent rhinoconjunctivitis


initial state = unasked
  • allergic_state.state = NULL
  • Cave: "unasked"

Doctor: Do you have any allergies ?

Patient:

no, not that I know

  • allergic_state.state = 0
  • allergic_state.comment = NULL
  • clin.allergy empty
  • Cave: shows Phi

no, but I suspect nuts

  • allergic_state.state = 0 or 1 (this depends on what the clinician prefers)
  • allergic_state.comment = "nuts suspected"
  • clin.allergy empty or row for "nuts suspected"
  • Cave: shows phi (0) or "?nuts" (1)

no (but clinician thinks that is not true)

  • allergic_state.state = 0 or 1 (depending on clinician)
  • allergic_state.comment = "patient says no but I do not trust her"
  • clin.allergy empty
  • Cave: shows phi "!?"

yes, but I have no idea which

  • allergic_state.state = 1
  • allergic_state.comment = "unknown triggers" or similar
  • clin.allergy empty
  • Cave: shows "!?"

yes, Penicillin and something else (which I do not know or will not tell)

  • allergic_state.state = 1
  • allergic_state.comment = "unknown additional triggers" or similar
  • clin.allergy row for penicillin
  • Cave: shows "Penicillin, ?"

yes, Penicillin and that is it

  • allergic_state.state = 1
  • allergic_state.comment = NULL
  • clin.allergy row for penicillin
  • Cave: shows "Penicillin"

The Cave: tooltip always shows sufficiently complete information.

Useful buttons in manager (common clinical situations):

  • no known allergies
    • will delete existing entries if any exist only after reconfirmation
  • yes, but unknown
  • reconfirm current state
    • time of last reconfirmation shown in Cave: field tooltip

Topic revision: 07 Apr 2010, KarstenHilbert
 
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