Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Document the reported allergic reaction to a specific medication.
Include the medication name, dosage, and route of administration.
Describe the details of the allergic reaction:
Onset (time after medication administration)
Symptoms (rash, hives, itching, wheezing, shortness of breath, angioedema, anaphylaxis)
Severity (mild, moderate, severe)
Resolution (spontaneous or with treatment)
Inquire about any past reactions to similar medications or allergies to other substances (food, latex).
Objective:
Vital Signs (if relevant to the reported reaction – document during or after the reaction)
Physical Exam (if relevant to the reported reaction – document during or after the reaction)
Look for signs of ongoing allergic reaction (rash, wheezing)
Assessment:
Document a suspected drug allergy to [medication name] based on the reported reaction.
Consider the severity of the reaction (anaphylaxis, other).
Indicate the level of certainty (e.g., highly probable, possible) based on the available information.
Plan:
Management:
If the allergic reaction is ongoing, document the treatment provided (e.g., antihistamines, steroids, epinephrine).
Documentation:
Update the allergy list in the electronic medical record (EMR) with the specific medication and reaction details.
Provide an allergy alert for future medication orders.
Discussion with Patient:
Educate the patient about the importance of avoiding the allergenic medication and informing other healthcare providers about the allergy.
Discuss alternative medications if needed.
Follow-up:
Depending on the severity of the reaction, consider scheduling a follow-up visit to monitor for any delayed reactions.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding the medication, reported reaction, assessment of allergy, and management plan. Consider consulting with an allergist for complex cases or uncertain diagnoses.