Audit of documentation of allergies in a psychiatric inpatient unit.

OBJECTIVES

This audit aimed to: identify the level of allergy documentation in admission notes, case notes and medication charts in the Department of Psychiatry, Portlaoise; establish the degree of compliance to the gold standard guidelines; highlight areas requiring further improvement and make realistic recommendations to ensure better compliance with the stipulated guidelines on allergy documentation; and re-audit after six months.

METHODS

Gold standard guidelines on allergy documentation were obtained from various sources. Audit was performed over three days during which data was collected from the allergy section of medication charts, current case notes and original admission notes in both acute and long-stay wards. Recommendations were made and some were adopted, changes to practice were implemented for six months; at which time re-audit was performed.

RESULTS

The initial audit revealed that: the allergy section was completed in 25% of medication charts; only 12% of current case notes had any documentation of allergy status; an for the original admission notes, the allergy section was documented in 65% of notes. Based on these results, a formal initial assessment proforma with a designated allergy section was introduced and a renewed awareness of the importance of the documentation of allergy status was actively promoted amongst non consultant hospital doctors (NCHDs). Six months later, re-audit showed that: in the medication charts there was a significant improvement in the level of compliance with documentation of allergy status (allergy or NKDA) in the allergy section up from 25% to 58.1%; in the current case notes, there was only marginal improvement in the level of compliance on the front of case notes from 12-19.1%; and in the original admission notes, there was also considerable improvement in the level of compliance with documentation of allergy status up from 65% to 80.9%.

CONCLUSION

This audit improved the level of documentation of allergy sections in the relevant areas and therefore helped in preventing avoidable and potentially fatal allergic reactions. It will also help save money for the Health Service Executive by reducing compensation costs filed by patients.