elga-cdaps-2.06.2 Diskussion:Allergien und Intoleranzen-Section (Template)

In ELGA sind die Allergien und Unverträglichkeiten im Entlassungsbrief ärztlich dokumentiert:

• Sektion Allergien, Unverträglichkeiten und Risiken
  
  • Sektion mit Freitext
    Sektionscode LOINC 48765-2 @displayName="Allergies, adverse reactions, alerts"

Definition im ILF Entlassungsbrief Ärztlich:

• Beschreibung der Allergien, Unverträglichkeiten und Risiken und deren beobachteten Nebenwirkungen, sowie sonstiger Risiken.

• Die Sektion „Allergien, Unverträglichkeiten und Risiken“ ist für die Empfänger des Entlassungsbriefes besonders wichtig und wird auch im ELGA-Referenz-Stylesheet prominent dargestellt.
• Wenn keine Allergie bekannt ist (und auch danach gefragt wurde), SOLL der Standardtext „Keine Allergie bekann**t“ angegeben werden (Empfehlung).
• Wenn weder Allergien, Unverträglichkeiten noch sonstige Risiken bekannt sind, kann die Sektion weggelassen werden

epSOS Definition der Allergien und Risiken epSOS sieht dafür im Patient Summary eine codierte Angabe vor:

• Allergies and Other Adverse Reactions Section with Allergies and Intolerances Concern entries

Sektionscode LOINC 48765-2 @displayName="Allergies, adverse reactions, alerts"

• Verpflichtende Level-3 Codierung:

"Allergies and Intolerances Concern Entry"

Alerts / Allergies and Intolerances [B / R] Beschreibung: "Description of the clinical manifestation of the allergic reaction. Example: anaphylactic shock, angioedema (the clinical manifestation also gives information about the severity of the observed reaction)"

• Allergies and Other Adverse Reactions Section [R]

"The adverse and other adverse reactions section shall contain a narrative description of the substance intolerances and the associated adverse reactions suffered by the patient. It shall include entries for intolerances and adverse reaction …"

• Allergies and Intolerances Concern Entry [R]
  • Allergy – the following data elements apply only the PS.
    • The field "alerts" was originally defined to include all the important and objective medical information that should be highlighted (such as allergies, thrombosis risk, immune deficit ...etc). When defining the content only allergies and intolerance to drugs appear to be the common understanding and the easiest to be transferred.
    • A lot of surveys are being made in different countries (not only in Europe) to make a more evidence-based definition of what should represented and should not byt the concept “alerts”, hence not enough information could be provided to take a further decision. As epSOS’s intention is not to duplicate information, this shall not be repeated. Alerts are diffucult to represent since they are contextual. Alerts may be represented as severe or life-threatening allergies or other adverse reactions. Another area are certain selected procedures and implanted devivces. The section Allergies and Other Adverse Reactions contains the medical alerts as well, based on the serverity, and their representation becomes a Country B choice
  • Medical alert information:
    • any other clinical information that is essential to know so that the life or health of the patient does not come under threat.
    • Example 1: Intolerance to aspirin due to gastrointestinal bleeding.
    • Example 2: intolerance to captopril because of cough (the patient is not allergic but cannot tolerate it because of persistent cough)
  • Allergy and Intolerance Concern Entry (ggf. noch geändert)