Allergies and Adverse Reactions Section Content
The Allergies and adverse reactions section carries information about the patient’s allergies and adverse reactions. PRSB Elements should be formatted as subheadings in any HTML sent. This table should be used in conjunction with the section on constructing clinical coded structures for further information on constructing and coding allergy lists.
|ALLERGIES & ADVERSE REACTIONS|
|Data Item||Description||Cardinality||Values||Mandatory/required/ optional||FHIR Target|
|Causative agent||The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this patient. Or “No known drug allergies or adverse reactions” Or “Information not available”.||1 ONLY||Choice of • Text • Coded text – constraint: SNOMED CT: NHS dm+d TF, NHS dm+d TFG, NHS dm+d VMP, NHS dm+d AMP, NHS dm+d Ingredients, NHS dm+d Combination drug VTMs, Or alternatively one of the following statements: “No known drug allergies or adverse reactions” Or “Information not available” (Comment coding for this should be reviewed as the GP2GP causative agent work reaches completion)||Mandatory||AllergyIntolerance.code|
|Description of reaction||A description of the manifestation of the allergic or adverse reaction experienced by the patient. For example, skin rash.||0 TO 1||Free text||Required||Text and if coding is available carried in the CodeableConcept of the AllergyIntolerance.reaction.manifestation FHIR element. If no coding available use AllergyIntolerance.reaction.description FHIR element.|
|Type of reaction||The type of reaction experienced by the patient (allergic, adverse, intolerance).||0 TO 1||allergy - intolerance||Required||AllergyIntolerance.type|
|Severity||A description of the severity of the reaction.||0 TO 1||mild - moderate - severe||Required||AllergyIntolerance.reaction.severity|
|Certainty||A description of the certainty that the stated causative agent caused the allergic or adverse reaction.||0 TO 1||unconfirmed - confirmed||Required||AllergyIntolerance.verificationStatus|
|Evidence||Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests.||0 TO 1||Reference (DiagnosticReport)||Required||Composition.section.text Note: structured FHIR Diagnostic Reports are not currently supported|
|Probability of recurrence||Probability of the reaction (allergic, adverse, intolerant) occurring.||0 TO 1||Free text||Required||Composition.section.text|
|Date first experienced||When the reaction was first experienced. May be a date or partial date (e.g. year) or text (e.g. during childhood).||0 TO 1||dateTime - Age - Period - Range - String||Required||AllergyIntolerance.onset[x]|
|Comment||Any additional comment or clarification about the adverse reaction.||0 TO 1||Free text||Required||Composition.section.text|
|Date recorded||The date that the reaction was clinically recorded/asserted. This will often equate to the date of onset of the reaction but this may not be wholly clear from source data.||0 TO 1||dateTime||Required||AllergyIntolerance.assertedDate|
Example Allergies and Adverse Reactions Section
Examples are illustrative only.
<!--<xml>--> <!--Allergies and adverse reactions--> <section> <title value="Allergies and adverse reactions"/> <code> <coding> <system value="http://snomed.info/sct"/> <code value="886921000000105"/> <display value="Allergies and adverse reactions"/> </coding> </code> <text> <status value="additional"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table width="100%"> <tbody> <tr> <th>Causative agent</th> <td>NHS dm+d TF</td> </tr> <tr> <th>Description of reaction</th> <td>Signs of a skin rash</td> </tr> <tr> <th>Type of reaction</th> <td>allergy</td> </tr> <tr> <th>Severity</th> <td>mild</td> </tr> <tr> <th>Certainty</th> <td>unconfirmed</td> </tr> <tr> <th>Probability of recurrence</th> <td>Until the cause of the allergy is determined the chances of it coming back are high.</td> </tr> <tr> <th>Date first experienced</th> <td>9-May-2018 10:00</td> </tr> <tr> <th>Comment</th> <td>Suggest refer to a dermatologist</td> </tr> <tr> <th>Date recorded</th> <td>10-May-2018 10:00</td> </tr> </tbody> </table> </div> </text> <!--Reference to Allergies List as the source of information for this section--> <entry> <reference value="urn:uuid:66204550-8e57-11e8-b568-0800200c9a66"/> </entry> </section> <!--</xml>-->
This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.
See constructing clinical coded structures - Allergy Lists