The Southern Medical Journal (SMJ) is the official, peer-reviewed journal of the Southern Medical Association. It has a multidisciplinary and inter-professional focus that covers a broad range of topics relevant to physicians and other healthcare specialists.
SMJ // Article
Primary Article
Antibiotic Allergy: Inaccurate History Taking in a Teaching Hospital
Abstract
ABSTRACT: To evaluate the accuracy of allergy histories obtained by interns, residents, and ward attending physicians, we compared physician-charted allergy histories with our own concurrently performed histories over a 2-month span for all general medicine and surgery patients admitted to a 615-bed suburban teaching hospital. We found 100% agreement between investigator and charted histories for all 318 (88%) of 363 charts identifying no known allergy. We disagreed with 23 (50%) of 46 allergies documented in the charts of the remaining 45 patients. Concurrent review classified 18 (39%) of these 46 charted allergies as clinically unimportant, and 5 charts (11%) were deemed underclassified. A description of the allergy by the primary physician was documented in only 7 charts (16%). Inaccurate allergy histories are frequently documented in the medical record. Simple adjustments in history taking and supervision may have important implications for patient care and training.This content is limited to qualifying members.
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