Allergic, hypersensitive, and intolerant reactions can be avoided by preventing the prescription and administration of, or exposure to known trigger substances. The proper documentation of known allergic, hypersensitivity, or intolerance episodes is critical to making this knowledge available at the point of care and supporting decision-making that would prevent future situations. Information needs to be recorded with the right level of detail and context to support these processes.
This page summarizes the key use cases covered by this guide. See section 4.3 for detailed examples.
Use Case 1: Documentation of Information Related to Allergy, Hypersensitivity, and Intolerance
Scenario 1.1: Documentation of an adverse reaction to a drug substance
Healthcare providers should be able to accurately record the details of a patient's adverse reaction to a drug substance. This information includes the drug substance involved, routes of administration, dosage, signs, and symptoms produced by the reaction, time frames, etc., allowing for clear and consistent documentation and communication between healthcare providers. This can improve patient care by facilitating a more accurate understanding of the reaction and facilitating the identification of potential risk factors. Additionally, the use of SNOMED CT can support research and data analysis on adverse drug reactions.
Scenario 1.2: Documentation of drug allergy in the allergy list and use as alert to provider
SNOMED CT can be used to document drug allergies in the allergy list and serve as an alert trigger to providers. This will allow providers to quickly and accurately identify drugs that a patient may be allergic to, for instance as they prescribe. SNOMED CT is used to identify potential allergy triggers in the patient's medical history and assist providers in determining the safest and most effective treatment options for the patient.
Scenario 1.3: Documentation of a food intolerance
Healthcare providers should be able to record the details of a patient's food intolerance accurately. This information includes the type of food, examination results, signs, and symptoms produced by the intolerance, time frames, etc., allowing for clear and consistent documentation and communication between healthcare providers. This can improve patient care by facilitating a more accurate understanding of intolerance events and facilitating the identification of potential risk factors. Additionally, the use of SNOMED CT can support research and data analysis on food intolerance, food allergies and cross reactivities.
Scenario 1.4: Documentation of animal allergy
Healthcare providers should be able to record the details of a patient's animal accurately. This information includes the type of animal, exposure, examination results, signs and symptoms produced by the allergy, time frames, etc., allowing for clear and consistent documentation and communication between healthcare providers. This can improve patient care by facilitating a more accurate understanding of his/her environmental allergic events and facilitating the identification of potential risk factors /situations. Additionally, the use of SNOMED CT can support research and data analysis on animal allergy.
Scenario 1.5: Documentation of allergy to non-medicinal substance cross-reacting with a pharmaceutical
SNOMED CT can be used to document non-medicinal substance allergies in the allergy list, which can cross-react with ingredients of medications or be an excipient in medications and thus serve as an alert to providers when prescribing a drug treatment. This will allow providers to quickly and accurately identify drug classes or specific branded drugs or drug forms a patient may be allergic to based on previously recorded allergies to non-medicinal ingredients. SNOMED CT is used to identify potential allergy triggers in the patient's medical history and assist providers in determining the safest and most effective treatment options for the patient.
Scenario 1.6: Documentation of allergic reaction to other non-medicinal substances
Healthcare providers should be able to record allergic reactions to other non-medicinal substances accurately. This information includes the type of non-medicinal substance, examination results, signs, and symptoms produced by the reaction, time frames, etc., allowing for clear and consistent documentation and communication between healthcare providers. This can improve patient care and general life by facilitating a more accurate understanding of allergic reactions and facilitating the identification of potential risk factors, situations or products to avoid in everyday life or protection equipment needed during professional exposure. Additionally, the use of SNOMED CT can support research and data analysis on allergic reactions.
Scenario 1.7: Documentation of ‘No Known Allergies’
Healthcare providers should be able to record when a patient reports that he/she has no allergy history, with the data and time of the report.
Use Case 2: Sharing of Information Related to Allergy, Hypersensitivity, and Intolerance
Scenario 2.1: Sharing adverse reaction data
Electronically-stored allergy, hypersensitivity and intolerance information information should be semantically interoperable to enable sharing of information across system, organization and geographic boundaries.
Use Case 3: Supporting the Implementation of Decision Support Systems
Scenario 3.1: Potential adverse reaction alerts
Electronic health records should be able to leverage the stored information to run clinical decision support systems to alert clinicians of potential adverse reactions due to allergy, hypersensitivity and intolerance.
