Immunotherapy Safety for the Primary Care ... - U.S. Coast Guard

Allergy Treatment Record Review
Chart ID: _________________ Reviewer: _________________ Date: _______________
1. All necessary forms present:
a. Intake questionnaire
b. Signed informed consent form
c. Current allergen extract prescription
d. Pre-shot questionnaire
e. Treatment form
f. Missed-dose/reaction AIT dose adjustment instruction
2. Patient identification on all forms. Name alert on chart cover.
3. Treatment form:
a. Legible
b. Drug/latex allergies documented
c. Current prescription number & therapy start date
d. Shot dates entered
e. Concentration (cap color/dilution) entered
f. Delayed reaction noted prior to administering shot
g. Document dose verified by patient/guardian
h. Dosages are correct per schedule with appropriate
adjustments as indicated
i. Arm(s) used noted
j. Immediate reaction noted prior to departing clinic
k. Entry initialed and initials correspond to signature
4. Asthma patient:
a. Chart flagged and minimum PF or FEV1 present
b. PF or FEV1 recorded prior to shot
c. No shot given and physician’s note if PF/FEV1 below
minimum (< 80% predicted or > 15% below baseline)
5. Nursing notes:
a. Dose changes documented on treatment form
b. Systemic reactions documented:
i. Vital signs recorded
ii. Treatment documented
iii. Physician note included
iv. Patient disposition documented
Yes No* N/A
Comments (note praise-worthy findings and explain all items answered No above):
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________________________________________________________________________
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Reviewer’s signature ________________________