AAAHC Publishes Allergy Documentation Benchmarking Study


AAAHC Publishes Allergy Documentation Benchmarking Study

The Accreditation Association for Ambulatory Health Care (AAAHC) of Skokie, Illinois, published a new Allergy Benchmarking study that underscores the importance of correctly documenting patients’ allergies—e.g., drugs, food, insects, latexes, molds, pets and pollens—to minimize risks of adverse reactions, according to a press release.

More than 50 million Americans suffer from allergies each year that, if not properly documented and addressed by healthcare professionals, can lead to potentially devastating consequences, according to the release. In addition to asking organizations about their adherence to AAAHC standards requiring allergies, sensitivities and reactions to be recorded in a prominent and consistent location in all clinical records, the study dug deeper by asking organizations about the best practice of documenting both the reaction or symptom (e.g., hives) and the severity of the reaction (e.g., mild, moderate, severe).

According to findings, although 86 percent of organizations reported having a policy requiring documentation of allergy symptoms/severity, documentation of both the symptom and the severity was present in only 41 percent of charts in which the patient had at least one allergy. This lapse can lead to inaccurate allergy documentation from one visit to the next, impacting healthcare decisions, the quality of patient care and, ultimately, a patient’s health.

“To have an accurate record of a patient’s allergy history, healthcare providers should consistently discuss and verify allergies with the patient during each visit and properly record existing or new allergies along with their symptoms and reactions,” said Tess Poland, RN, senior vice president of accreditation services at AAAHC, in the release. “As the COVID-19 pandemic continues, it is especially important to have these conversations with patients. Differentiating allergy versus COVID-19 symptoms can help ensure that the patient receives the correct treatment.”

The study analyzed self-reported data from 81 AAAHC-accredited surgical and primary care organizations, reviewing more than 1,705 patient charts with at least one allergy between January–June 2020. The survey data indicates that common issues in allergy documentation include:

  • Allergies have not been verified/updated on each visit.
  • Documentation regarding allergies is inconsistently located in clinical records.
  • “Allergies” are listed, but reactions are not.
  • There is a reliance on “NKDA” (No Known Drug Allergies) without reference to other types of allergies/sensitivities.
  • Allergic reaction documentation is inconsistent.

In addition to the benchmarking study, AAAHC published a toolkit on this topic that provides guidance and best practices for effective allergy documentation. To help organizations improve quality of care when it comes to allergies, the Allergy Documentation Toolkit includes an overview of challenges and improvement strategies, as well as more specific discussions about latex and penicillin/beta-lactam allergies. Complementing the toolkit is a webinar series focusing on medication management which features an hourlong presentation on allergy documentation.