Allergic Immunologic

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General Section

SKILLED DOCUMENTATION GUIDELINES — EXPANDED

DiraChart · Clinical Reference · Read-only baseline inherited by all agencies

Body System Reference · 2.36

Allergic / Immunologic

Allergy, anaphylaxis, and immune function. Routed here: allergy history and reactions, anaphylaxis recognition and response, immunocompromise and infection susceptibility, immunosuppressant monitoring, vaccine status, allergen avoidance, and epinephrine auto-injector teaching. The airway in anaphylaxis is shared with Mouth/Oral and Respiratory; neutropenia and blood-count effects are shared with Hematologic.

Module code

SYS-ALLERGIC-IMMUNO

Version

1.0 · Population: Adult · Authoring level: DiraChart (read-only baseline; agencies may append)

Used alongside

Mouth / Oral (airway) · Respiratory · Hematologic (neutropenia) · Vital Signs

How to use this module

This module supplies the allergy and immune assessment and, above all, anaphylaxis recognition and response — with the skilled language that proves the care took a licensed nurse. The single most important rule in this module is that epinephrine is given first in anaphylaxis and EMS is activated immediately after — epinephrine is never delayed. Airway management is shared with Mouth/Oral and Respiratory; neutropenia with Hematologic. Each narrative is a structured example to edit to the actual visit and the patient’s orders — not a phrase to copy.

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