How should allergies be documented and communicated in the clinic chart?

• A. Document all allergies, reaction, and severity; verify at each visit; flag in the chart and use allergy alerts in the EHR; communicate to all care team.
• B. Document allergies only if the patient reports a reaction.
• C. Document allergies in the chart, but do not verify at subsequent visits.
• D. Document allergies but only share them with the primary physician.

Answer: (C)

Accurate, complete allergy documentation and clear communication across the care team are essential for patient safety. Every known allergy should be captured with what happened and how severe the reaction was, so clinicians can choose medications safely. At every visit, take a moment to review and verify the allergy list—don’t assume it’s the same as last time, and update it if the patient or family reports new information. This verification helps catch new allergies or changes in how the patient reacts.

Flagging allergies in the electronic health record with alerts ensures that orders for medications or drug classes trigger warnings and guide alternatives, reducing the risk of adverse reactions. Sharing this information with the entire care team—nurses, pharmacists, specialists, and any other providers involved in the patient’s care—creates a consistent safety net, so everyone knows what to avoid and what to monitor.

Explain to patients that reporting new reactions promptly is important, and document these updates quickly so future visits benefit from the most current information.