Inclusion criteria
- •Adult patients aged 16 years or older
- •Patients admitted to hospital, an assessment unit or a same-day emergency care area
- •Inpatient, ambulatory or day-case episodes where allergy status should be recorded under local policy
- •Cases from selected wards, departments, specialties or services during the audit period
- •Electronic, paper or hybrid records depending on local setup
Exclusion criteria & limitations
- •Patients under 16 years old (unless the tool is locally adapted for paediatric use)
- •Obstetric or maternity records unless the tool is locally adapted
- •Cases where local governance approval has not been obtained
- •Records outside the selected audit period
- •Duplicate admissions or duplicate records for the same episode
- •Records unavailable for review
- •Direct patient identifiers must not be entered into the tool
Audit criteria (26)
Aligned with NICE CG183 (Drug allergy: diagnosis and management), NICE QS97 (Drug allergy) and local trust drug allergy policy. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
- C1Allergy status was documented in the clinical record.Target ≥ 90% · auto-computed from submissions
- C2Allergy status was documented in the prescribing or medicines administration system.Target ≥ 90% · auto-computed from submissions
- C3Allergy status was visible at the point of prescribing or administration.Target ≥ 90% · auto-computed from submissions
- C4No known allergy status was explicitly documented where applicable.Target ≥ 90% · auto-computed from submissions
- C5Allergy status was reviewed during medicines reconciliation where medicines reconciliation was required.Target ≥ 90% · auto-computed from submissions
- C6Allergy information was verified with an appropriate source where possible.Target ≥ 85% · auto-computed from submissions
- C7Source of allergy information was documented.Target ≥ 85% · auto-computed from submissions
- C8Drug or allergen name was documented where an allergy or suspected allergy was present.Target ≥ 90% · auto-computed from submissions
- C9Drug class was documented where relevant.Target ≥ 80% · manual review
- C10Reaction signs or symptoms were documented.Target ≥ 90% · auto-computed from submissions
- C11Reaction severity was documented.Target ≥ 85% · auto-computed from submissions
- C12Reaction timing, approximate date or circumstances were documented where available.Target ≥ 80% · auto-computed from submissions
- C13Documentation distinguished allergy from intolerance, side effect or adverse drug reaction where possible.Target ≥ 85% · auto-computed from submissions
- C14Allergy status was coded or structured correctly where the EPR / prescribing system supports coding.Target ≥ 85% · auto-computed from submissions
- C15Allergy information was consistent across clinical notes, prescribing record and discharge/transfer documentation.Target ≥ 90% · auto-computed from submissions
- C16Allergy alert or prescribing warning was present where relevant and supported by the system.Target ≥ 85% · auto-computed from submissions
- C17Allergy-related prescribing discrepancy was actioned where identified.Target ≥ 90% · auto-computed from submissions
- C18New suspected drug allergy during admission was added to the allergy record where relevant.Target ≥ 90% · manual review
- C19Patient was informed about new suspected drug allergy where appropriate.Target ≥ 85% · manual review
- C20Written or structured allergy information was provided where relevant and locally required.Target ≥ 80% · manual review
- C21Specialist allergy referral was completed where indicated by local policy or severe reaction history.Target ≥ 85% · manual review
- C22Allergy status was included in discharge summary or transfer communication.Target ≥ 90% · auto-computed from submissions
- C23Drug/allergen and reaction details were included in discharge communication where relevant.Target ≥ 85% · auto-computed from submissions
- C24Reason for incomplete, missing or inconsistent allergy documentation was recorded where applicable.Target ≥ 80% · auto-computed from submissions
- C25Documentation was clear enough for another clinician, nurse or pharmacist to prescribe or administer medicines safely.Target ≥ 90% · auto-computed from submissions
- C26Any allergy-related medication safety concern was escalated or actioned where identified.Target ≥ 100% · auto-computed from submissions