Documentation of an adverse reaction to a drug substance

Scenario: A physician sees a patient in clinic for routine outpatient care.  Recently the patient was prescribed penicillin V 500 mg orally two times daily x 10 days for streptococcal pharyngitis. He tells the physician that he has developed hives the previous week and on examination, the physician confirms the presence of generalized hives. He records this in the patient record as an Observation.

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Figure 11: SNOMED CT inferred definition of concept 91936005 |Allergy to penicillin (finding)|as in the International Edition version 20220831.

Documentation in drug allergy list by provider and use as allergy alert

Scenario: Several years later, the patient from scenario 4.1 who has since received an aortic valve replacement is seeing another physician within the organization for consultation on antibiotic prophylaxis for an upcoming dental procedure. The second physician decides that a penicillin class antibiotic is appropriate for the patient. 

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*The use of a SNOMED CT concept to represent theses values requires the use of a FHIR extension in HL7® FHIR® v4.3.0: R4B - STU (see 2.2.3.1).

Documentation of a food intolerance

Scenario: A 34-year-old female is seen by her primary care provider for complaints of abdominal pain, bloating and change in bowel habits within hours or a few days after ingesting whole wheat bread. In addition, she complains of feeling tired but denies itching rash or wheezing. Those complaints are entered as observations in the EHR.

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Figure 12: SNOMED CT inferred definition of concept 700095006 |Intolerance to wheat (finding)| as in the International Edition version 20220831.

Sharing adverse reaction data

Scenario: The patient from scenario 4.1 is planning a vacation with his family consisting of a cross-country camping trip.  In preparation for travels, he speaks to his physician in hospital A and obtains an electronic summary of his healthcare record on a flash drive for himself, his wife and children. His physician informs him that the summary software includes an electronic ‘reader’ as well as a standard format that can be imported into another EHR for patient care.  Their vacation unfolds happily until, many miles from home the patient experiences an episode of right ear pain and is taken to a local emergency room in hospital B.  He provides the flash drive with his electronic record summary to the emergency room physician whose hospital employs an EHR which can accept FHIR extracted electronic record summaries for integration into the on-site health record system.  The emergency room nurse loads the flash drive and accepts the electronic copy of the problem list, allergies and medication list into the on-site record.  The software extract manages the differences in information model design between EHR vendors by crosschecking the allergy list with information in the problem list and encounter diagnoses.

After an otoscopic exam, the patient is diagnosed with acute otitis media. The emergency room physician enters an electronic order for “875 mg amoxiliin with clavulanate 125 mg orally twice daily”, the drug of choice for acute otitis in adults.  When the physician presses ‘Enter’ to commit the order, a pop-up alert is generated by the EHR with warning that this patient has had an allergic reaction to penicillin and has a high likelihood of cross reacting.  While studying the alert, the physician notes that the supporting information was gleaned from the problem list and allergy list.  The EHR drug interaction software has cross-referenced the chemical composition of amoxillin/ clavulanate and noted amoxiliin to be a penicillin derivative.  The physician decides that the information of penicillin allergy is credible and as the patient has taken cephalosporins in the past without issues, the physician changes his order to Cefuroxime, 500 mg orally twice daily.

Documentation of animal allergy or hypersensitivity

The causative agent for the realization of an allergic process directed against a living organism (plant or animal) is not the organism itself or a part of the organism such as epithelium but in most cases is a protein derived from the organism. An allergy to an animal should therefore be modeled with a causative agent that is a descendant of 272169002 |Animal protein (substance)| as in the concept below.

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*The use of a SNOMED CT concept to represent theses values requires the use of a FHIR extension in HL7® FHIR® v4.3.0: R4B - STU (see 2.2.3.1).

Documentation of adverse reaction to a non-medicinal substance cross reacting with a pharmaceutical

Scenario: A patient’s mother reports to their child’s physician that the child reacts violently to eating peanuts with symptoms that include generalized hives, wheezing and hypotension requiring use of epinephrine for resuscitation.  The physician obtains a blood test which documents high levels of IgE antibody against the Arachis h2 peanut protein which is found in unrefined peanut oil (Arachis oil) - the sensitizing agent for clinical peanut allergy. Ara h2 is associated with a risk of severe reactions to peanut.  The physician records a peanut allergy in the EHR with anaphylaxis, hives and wheezing as reaction symptoms, records a criticality of high and reaction severity of ‘severe’. 

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Years later, the youngster is seen by a dermatologist for treatment of acne.  As part of the plan of care, the physician enters an electronic prescription for Isotretinoin capsules.  When the physician commits the order, the EHR software runs allergy cross checking and issues a high priority alert that the capsules contain peanut oil that is not highly refined and therefore may potentially include peanut protein and are contraindicated for the patient.  The physician cancels the order and chooses an alternative preparation.

Documentation of adverse reaction to other non-medicinal substances

Scenario:  A licensed nurse presents to her personal physician for recurring problems of a generalized rash and itching.  She works in an intensive care unit and is constantly handing chemicals, disinfectants, assisting in surgical procedures and performing catheter cares for her patients.  As a part of the health history, she noticed that she had an eruption on her hands after handling latex catheters.  Additionally, she reports a serious allergic reaction to papaya in the past and has been careful in the fruits she eats as a consequence.  The clinician suspects a latex allergy cross-reacting with foodstuffs and orders IgE testing for Hevea latex antibody.  The serology testing is strongly positive and the clinician advises the nurse of his findings with warnings about other foods, which may cross react.  While documenting the clinical encounter, he records a latex allergy in the allergy list.

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*The use of a SNOMED CT concept to represent theses values requires the use of a FHIR extension in HL7® FHIR® v4.3.0: R4B - STU (see 2.2.3.1).

Recording of ‘No known allergies’

Scenario:  A nurse is performing an intake examination on a patient that is new to the clinical practice.  As part of the clinical interview, he inquires about medication and other allergies.  The patient reports that she is not allergic to any medications, foods, chemicals or animals.  The nurse opens the ‘allergy list’ in the EHR and documents ‘No known allergies’ which electronically validates that the nurse inquired of the patient and that the history was confirmed negative at the date and time recorded.  This satisfies decision support criteria that allergies be documented before medication orders are written and is encoded in the EHR allergy list as confirmed absence of dispositions to adverse reactions.

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