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Release Notes:
Data Element
Version 2010A1

Data Element Name: Antibiotic Allergy
Collected For: PN-6, PN-6a, PN-6b, SCIP-Inf-2,
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.
Suggested Data Collection Question:Did the patient have any allergies, sensitivities or intolerance to beta-lactam/penicillin antibiotic or cephalosporin medications?
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.

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.”
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
Additional Notes:
Guidelines for Abstraction:
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.

  • None

Antibiotic Allergy
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)