Aim of the Study
The purpose of the audit was to see if allergies were being recorded in patient notes and if the notes were consistent in different records belonging to the same person. e.g. on drug chart as well as on EPR.
Historically such an audit would be carried out by manually reviewing the individual patients clinical records held in the Electronic Patient Record (EPR). Using Akrivia’s Platform makes it easier as reports can be generated using a search criteria that would identify patients who fit the specifics and the output would be in a table format that is easy to then analyse how information is being recorded.
The Trust wanted to find all patients that had any allergy recorded in the EPR to enable them to check:
- Recording of drug allergy status
- Documenting of new suspected drug allergies
- Maintaining and sharing drug allergy information
- Providing information and support to patients
The study has found that allergy recording in the EPR was inconsistent and data recording practices varied by clinician. E.g. Adverse effects were being recorded in error as an allergy, rather than an adverse effect.
To support the clinicians and address the issue a ‘How to’ record allergies in the EPR system guide was introduced. A follow-up audit was done to find out if the introduction of ‘How to’ guide has resolved the issue has indicated that the introduction of the guide has been effective and data capturing has significantly improved.