Drug allergy documentation by physicians, nurses, and medical students.
The completeness and accuracy of drug allergy documentation by medical residents, medical students, and primary-care nurses in a 450-bed teaching hospital were assessed, along with patients' knowledge of their drug allergy status. During a three-month period, the current admission notes written by medical residents, medical students, and primary-care nurses for adult medicine patients with drug allergies were reviewed by a pharmacy student. Patients with drug allergies were identified by the presence of drug hypersensitivity labels on the front of the medical charts. The student collected information about each reaction and determined whether it was a true allergic reaction, a nonallergic adverse reaction, or unclassifiable. A second pharmacy student interviewed the same patients whose medical charts had been reviewed and asked seven open-ended questions about the allergy status of each patient. For the 49 patients included in the study, 75 drugs were listed as allergens on the front of the patients' charts and 78 drugs were reported as allergens during patient interviews; only 66 of those drugs were identified both on the charts and by the patients. Approximately 20% of the health-care professionals failed to document the drug allergies in their admission notes. Although the majority of patients could recall the dosage form of the offending drug, the time that had elapsed between administration of the drug and appearance of symptoms, and how long ago the reaction had occurred, none of this information was recorded by the health-care professionals. Incomplete documentation of the drug allergy status of patients in our hospital does not appear to be related to patients' inability to provide accurate information.