Nursing education for proper drug allergy documentation

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Karen Thompson
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Joined: 05/03/2009 - 02:30
Nursing education for proper drug allergy documentation

I've been asked to put together a 1 page educational flyer for nursing about how to properly document medication allergies. I wanted to see if anyone had already done this before I reinvent the wheel. Problems we see with documentation:
-RNs document known side effects as allergies (opioids cause sedation)
-RNs document as an allergy, when "intolerance" or "contraindication" is the more appropriate classification
-If pt reports a family history of an allergic reaction to a med, RN enters it as a patient allergy
-RN does not enter the reaction detail in the documentation

thanks