Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Antibiotic Allergy |
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| Collected For: | PN-6, PN-6a, PN-6b, SCIP-Inf-2, |
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| Definition: | Documentation that the patient has an allergy, sensitivity, or intolerance to penicillin, beta lactams, or cephalosporins. An allergy can be defined as an acquired, abnormal immune response to a substance (allergen) that does not normally cause a reaction. |
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| Suggested Data Collection Question: | Did the patient have any allergies, sensitivities or intolerance to beta-lactam/penicillin antibiotic or cephalosporin medications? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) Documentation that the patient has an antibiotic allergy to beta-lactam, penicillin, or cephalosporins (e.g., either history or current finding).
N (No) No documentation that the patient had an allergy to beta-lactam, penicillin, or cephalosporins or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- If the patient was noted to be allergic to “cillins,” “penicillin,” or “all cillins,” select “Yes.”
- If one source in the record documents “Allergies: penicillin” and another source in the record documents “penicillin causes upset stomach,” select “Yes.”
- If a physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist documents a specific reason not to give penicillin, beta-lactams, or cephalosporins, select “Yes.”
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Nursing notes
- Nursing admission assessment
- Progress notes
- Physician orders
- Medication administration record (MAR)
- ICU flowsheets
For SCIP-Inf, in addition to the above suggested data sources, the following may also be utilized:
- Anesthesia record
- Operating room notes
- PACU/recovery room record
- Pre-anesthesia assessment
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
Symptoms include:
- Adverse drug event
- Adverse effect
- Adverse reaction
- Anaphylaxis
- Anaphylactic reaction
- Hives
- Rash
Refer to Appendix C, Table 4.0, Antibiotic Allergy Table.
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Antibiotic Allergy
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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