Gives information about the Allergies and Adverse reactions section

Important: This specification is based on the Professional Records Standards Body's Pharmacy information flows standard which provides further information on document headings and content: https://theprsb.org/standards/pharmacyinformationflows1and2/

Allergies and Adverse Reactions Section Content

The Allergies and adverse reactions section carries information about the patient’s allergies and adverse reactions. PRSB Elements should be formatted as subheadings in any HTML sent. This table should be used in conjunction with the section on constructing clinical coded structures for further information on constructing and coding allergy lists.

ALLERGIES & ADVERSE REACTIONS
Data Item	Description	Cardinality	Values	Mandatory/required/ optional	FHIR Target
Causative agent	The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this patient. Or “No known drug allergies or adverse reactions” Or “Information not available”.	1 ONLY	Choice of • Text • Coded text – constraint: SNOMED CT: NHS dm+d TF, NHS dm+d TFG, NHS dm+d VMP, NHS dm+d AMP, NHS dm+d Ingredients, NHS dm+d Combination drug VTMs, Or alternatively one of the following statements: “No known drug allergies or adverse reactions” Or “Information not available” (Comment coding for this should be reviewed as the GP2GP causative agent work reaches completion)	Mandatory	AllergyIntolerance.code
Description of reaction	A description of the manifestation of the allergic or adverse reaction experienced by the patient. For example, skin rash.	0 TO 1	Free text	Required	Text and if coding is available carried in the CodeableConcept of the AllergyIntolerance.reaction.manifestation FHIR element. If no coding available use AllergyIntolerance.reaction.description FHIR element.
Type of reaction	The type of reaction experienced by the patient (allergic, adverse, intolerance).	0 TO 1	allergy - intolerance	Required	AllergyIntolerance.type
Severity	A description of the severity of the reaction.	0 TO 1	mild - moderate - severe	Required	AllergyIntolerance.reaction.severity
Certainty	A description of the certainty that the stated causative agent caused the allergic or adverse reaction.	0 TO 1	unconfirmed - confirmed	Required	AllergyIntolerance.verificationStatus
Evidence	Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests.	0 TO 1	Reference (DiagnosticReport)	Required	Composition.section.text Note: structured FHIR Diagnostic Reports are not currently supported
Probability of recurrence	Probability of the reaction (allergic, adverse, intolerant) occurring.	0 TO 1	Free text	Required	Composition.section.text
Date first experienced	When the reaction was first experienced. May be a date or partial date (e.g. year) or text (e.g. during childhood).	0 TO 1	dateTime - Age - Period - Range - String	Required	AllergyIntolerance.onset[x]
Comment	Any additional comment or clarification about the adverse reaction.	0 TO 1	Free text	Required	Composition.section.text
Date recorded	The date that the reaction was clinically recorded/asserted. This will often equate to the date of onset of the reaction but this may not be wholly clear from source data.	0 TO 1	dateTime	Required	AllergyIntolerance.assertedDate

Example Allergies and Adverse Reactions Section

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->
<!--Allergies and adverse reactions-->
				<section>
					<title value="Allergies and adverse reactions"/>
					<code>
						<coding>
							<system value="http://snomed.info/sct"/>
							<code value="886921000000105"/>
							<display value="Allergies and adverse reactions"/>
						</coding>
					</code>
					<text>
						<status value="additional"/>
						<div xmlns="http://www.w3.org/1999/xhtml">
							<table width="100%">
								<tbody>
									<tr>
										<th>Causative agent</th>
										<td>NHS dm+d TF</td>
									</tr>
									<tr>
										<th>Description of reaction</th>
										<td>Signs of a skin rash</td>
									</tr>
									<tr>
										<th>Type of reaction</th>
										<td>allergy</td>
									</tr>
									<tr>
										<th>Severity</th>
										<td>mild</td>
									</tr>
									<tr>
										<th>Certainty</th>
										<td>unconfirmed</td>
									</tr>
									<tr>
										<th>Probability of recurrence</th>
										<td>Until the cause of the allergy is determined the chances of it coming back are high.</td>
									</tr>
									<tr>
										<th>Date first experienced</th>
										<td>9-May-2018 10:00</td>
									</tr>
									<tr>
										<th>Comment</th>
										<td>Suggest refer to a dermatologist</td>
									</tr>
									<tr>
										<th>Date recorded</th>
										<td>10-May-2018 10:00</td>
									</tr>
								</tbody>
							</table>
						</div>
					</text>
					<!--Reference to Allergies List as the source of information for this section-->
					<entry>
						<reference value="urn:uuid:66204550-8e57-11e8-b568-0800200c9a66"/>
					</entry>
				</section>
<!--</xml>-->

Coded Resources

This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.

• List
• AllergyIntolerance

See constructing clinical coded structures - Allergy Lists

Tags: fhir