Assessing Recording of Allergy Status on Rio Amongst Patients in Sandwell CAMHS

Abstract

Aims

To assess recording of allergy status for patients under the care of Sandwell CAMHS

Methods

This audit was performed at Sandwell CAMHS. The project was discussed and logged with the Trust's audit department.

Medical records of all patients (516 patients) seen between January and March 2022 by the medics in Sandwell CAMHS were examined for documentation of allergy status

For all patients the alert bar on Rio was examined to determine whether or not their allergy status was recorded.

A data collection tool was devised to collect information in accordance with the standard i.e, the drug allergy recorded or not and when recorded;

• • it is present

• • no known allergy

where present;

• • substance name

• • reaction

• • severity

• • date recorded

• • Evidence and Certainty

Results

For the Recording of Allergy Status on Rio, the audit revealed:

1. A. 60 out of the 516 patients had their allergy status recorded.

Out of these 60 patients;

18 had possible allergy

42 had no known allergies

• B. 456 had no recordings of allergy status

• C. Those with possible Allergies;

The substance name was documented for all in Rio for those who had allergies indicated

12 of the 18 possible allergies had the allergic reaction documented

13 of the 18 possible allergies had the severity documented

3 of the 18 possible allergies had the date recorded

1 of the 18 possible allergies had evidence and certainty recorded

Conclusion

The audit revealed a poor recording of the allergy status

The following recommendations have been made:

Present audit at the Specialist mental health quality improvement group.

Clinicians should be made aware of the expected Nice Guidelines for documentation of allergy status.

Clinicians to update allergy status of patients every 6-12 months.

Develop an action plan and governance documentation with the specialist mental health quality improvement group.

The results of this audit have been shared with the Rio lead for them to consider making relevant changes in Rio i.e. The systems should include prompts for annual updates of allergy status.

A clear trust policy of documentation on how allergy status/adverse effects will be should be recorded Rio.

If possible, it should be included in the junior doctors' handbook and the eLearning.

To carry out a re- audit in 6 months to 1 year