# Documenting Rx Allergies



## catrina.thomas (Apr 3, 2012)

Which part of the history is documenting medication allergies given to?  Can it be counted in the ROS?


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## FTessaBartels (Apr 3, 2012)

*Can count as EITHER, but NOT both*

It can count as EITHER ROS or Past Medical History, but NOT both (for the same note).  Use it where you need it.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## kellyross (Apr 27, 2012)

I agree.... if you have enough in the Past Medical History already... I usually pull allergies into ROS, as well.


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## ajfinn0216 (Apr 27, 2012)

I do not agree.  Documentation of drug allergies should not be counted in the ROS.

A ROS should not be confused with the past history.  

ROS asks the patient whether or not he/she is *currently experiencing *any symptoms related to specific organ systems.  

Medical history is just that - the patient's past experiences with illness, operations, injuries and treatments.  This would include a medication list, surgeries, previous hospitalizations, problem list, etc....

Angie Finnigan, CCS-P, CPMA, CPC


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## kellyross (Apr 30, 2012)

I would say if they were allergic in the past... then it would be safe to assume that they are still "currently" allergic.  When questioning a patient about allergies - it would seem to be pertinent to the ROS and important in deciding the current treatment.... such as prescription management? 

Also, Allergy/Immunology is listed as a valid body system to document on. 

I guess it all depends how you're looking at it.  I would still count it in my ROS if I already had a past medical history documented somewhere else.


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## kellyross (May 1, 2012)

*a couple excerpts from 2 diff references*

***** these infer that medication allergies are fair game for ROS*****

*Allergic/Immunologic/Lymphatic/Endocrine **Reactions to drugs*, food, insects, skin rashs, trouble breathing 
Anemia, bleeding tendency, previous transfusions and reactions, Rh incompatibility 
Local or general lymph node enlargement or tenderness. -Polydipsia, polyuria, asthenia, hormone therapy, growth, secondary sexual development, intolerance to heat or cold 

*Allergic/Immunologic/Lymphatic/Endocrine *Difficulty breathing" or "choking" (anaphylaxis) as a result of exposure to anything (and state what; e.g. "bee sting"). Swelling or pain at groin(s), axilla(e) or neck (swollen lymph nodes/glands), *allergic response (rash/itch) to *materials, foods, animals (e.g. cats); *reaction to *bee sting, unusual sneezing (in response to what), runny nose or itchy/teary eyes; food, *medication* or environmental allergy test(s) results.


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