Pediatric Coding Alert

Reader Question:

Classify Allergies Correctly During Patient's Evaluation

Published on Thu Aug 18, 2011

Question: The pediatrician documented NKDA (no known drugallergies) as part of a patient's evaluation. Can we count this as part of the "allergic" portion of review of systems?

North Carolina Subscriber

Answer: The correct place to document allergy status depends on the patient's situation. Consider an active allergy as part of the review of systems (ROS); classify the allergy as part of the patient's past/personal history if the allergy is not currently present but might be related to the chief complaint.

Caveat: Exceptions pertain to ongoing circumstances such as a penicillin allergy. Always consider this type of allergy "active" because administering a dose ofpenicillin to test the status might kill the patient.

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