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Updated: Dec 19, 2025

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Improving Allergy Documentation: A Retrospective Electronic Health Record System-Wide Patient Safety Initiative.

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This study reduced over 130,000 free-text allergy entries in electronic health records (EHR). This improves clinical decision support and patient safety by promoting coded allergy documentation.

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Area of Science:

  • Health Informatics
  • Patient Safety
  • Clinical Decision Support

Background:

  • Accurate allergy documentation in electronic health records (EHR) is crucial for triggering clinical decision support and preventing adverse events.
  • Health system-wide initiatives to enhance EHR allergy documentation by reducing free-text entries have not been widely reported.
  • Free-text allergy entries can lead to inconsistencies and hinder effective clinical decision support.

Purpose of the Study:

  • To systematically reduce the number of free-text allergen entries within the EHR allergy module.
  • To improve the accuracy and usability of allergy data for patient safety.
  • To transition towards standardized, coded allergy documentation.

Main Methods:

  • A commercial EHR system at a multihospital integrated health care system was assessed for free-text allergy entries.
  • A multidisciplinary group used manual and automated methods to prioritize high-risk free-text allergens for conversion to coded entries.
  • New allergen entries were added, duplicates were deleted, and environmental allergies were moved to the patient problem list.

Main Results:

  • Over 242,000 free-text entries were identified, with environmental allergies (42%) and food allergies (18%) being most common.
  • Medical assistants and registered nurses were the primary contributors to free-text entries.
  • A total of 131,784 free-text entries were remediated using a combination of automated (52,206) and manual (79,578) methods.

Conclusions:

  • The multidisciplinary intervention successfully remediated a significant number of free-text allergy entries, enhancing EHR data quality.
  • Further strategies are necessary to completely eliminate free-text allergy documentation.
  • Establishing systematic, consistent, and safe guidelines for allergy documentation is essential for ongoing patient safety improvements.