Allergy Documentation Audit

This project audits whether allergy status is documented reliably and safely in the clinical record and prescribing systems. It reviews whether allergy status is recorded and categorised, checked with the person, carer or a reliable source, described with substance, reaction, timing and severity, distinguished from intolerance, visible and consistent across systems, reviewed at medicines reconciliation, considered in prescribing, updated when new information emerges, communicated at discharge and escalated for specialist advice where local policy requires it.

• Doctors, nurses, pharmacists and pharmacy technicians
• Medicines optimisation, antimicrobial stewardship and perioperative teams
• Acute medicine, emergency department and primary care teams
• Digital, EPR and ePMA teams where allergy coding is audited
• QI leads, governance teams, supervisors and educators

• Measure whether allergy status is documented, categorised and verified
• Assess the clinical meaningfulness of recorded allergy detail
• Identify visibility, coding, duplication and consistency problems across systems
• Review whether allergy status is considered at reconciliation, prescribing and discharge
• Generate governance-ready and ARCP-ready evidence and a re-audit cycle

• Anonymous case identifier
• Inclusion / eligibility decision
• Anonymised context (age band, sex/gender recorded, care setting, assessment context)
• Clinical area / location and optional specialty / service
• Eighteen allergy documentation criteria (met / not met / not applicable)
• Free-text learning points and any project custom fields

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

This ready-built project is developed using the guidance, standards and authoritative sources listed below, so you can see what is being measured and why. Lazomis QI does not publish or own this guidance, and inclusion here does not imply endorsement or approval by any of these organisations.

• NICE

  Drug allergy: diagnosis and management (CG183)(opens the original source in a new tab)

  National guideline on documenting and communicating drug allergy status, reaction detail and structured allergy records.

• NICE

  Drug allergy quality standard (QS97)(opens the original source in a new tab)

  Quality statements on recording drug allergy status, reaction detail and communicating allergy information at transfer of care.

• NHS England

  National Patient Safety Alert: harm from incorrect recording of penicillin allergy as penicillamine allergy(opens the original source in a new tab)

  Safety alert on allergy coding errors in electronic systems and the resulting prescribing risk.

• NHS England / NHS Digital

  DAPB4013: Medicine and Allergy/Intolerance Data Transfer(opens the original source in a new tab)

  Information standard for structured transfer of medicine and allergy / intolerance information between care settings.

• Local policy

  Local allergy documentation, medicines reconciliation, ePMA coding, prescribing and discharge communication policies

  Local policy defines allergy coding frameworks, alert configuration, reconciliation timing, prescribing rules and transfer-of-care standards. Confirm the local standard before setting targets.

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports documentation review only. It does not provide patient-specific prescribing advice and does not diagnose or de-label allergy.
• Allergy coding frameworks, alert configuration, ePMA workflows and medicine-specific rules are locally configurable and are not presented here as national standards.
• Use anonymous case identifiers only — never patient-identifiable information.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Clinical GovernanceLeveraging Incident Themes for Quality Improvement and Patient SafetyThis guide helps NHS teams identify and analyse recurring incident themes, transforming reported safety events into practical quality improvement opportunities to enhance patient safety and system reliability.
• Patient SafetyIntegrating Patient Safety and Quality Improvement: A Practical Guide for UK CliniciansThis guide explains the foundational principles of patient safety and quality improvement (QI) within the UK healthcare context, offering practical strategies for clinicians to enhance safety and improve care delivery.
• Patient SafetyHow to Select a Patient Safety Quality Improvement ProjectThis guide helps NHS teams identify and select patient safety quality improvement (QI) projects that are impactful, achievable, and aligned with organisational and national priorities. Learn how to move from identifying concerns to choosing a focused and measurable project.
• Patient SafetyReducing Handover Failures for Safer Patient CareEffective clinical handover is critical for patient safety, yet failures remain a significant contributor to adverse events. This guide explores the common pitfalls and offers practical, evidence-based strategies to improve handover processes across healthcare settings.