A complete allergic and immunologic assessment addresses each of the following as indicated by the patient’s condition and orders, and compares each finding to baseline.
Allergy history — the reconciled list of allergies and the nature and severity of prior reactions.
Current reaction signs — urticaria, angioedema, wheeze or stridor, gastrointestinal symptoms, and hypotension suggesting an allergic reaction or anaphylaxis.
Anaphylaxis readiness — the availability and expiration of the epinephrine auto-injector, the patient’s and caregiver’s technique, and the action plan.
Immune status — immunosuppressant therapy, transplant status, or a condition causing immunocompromise, and the resulting infection risk (neutropenia is documented with Hematologic).
Infection surveillance — fever and infection signs, treated as urgent in immunosuppression.
Immunosuppressant monitoring — the regimen, adherence, and signs of toxicity or adverse effects.
Vaccine status — currency of recommended vaccinations within the patient’s plan.
Allergen exposures — known triggers in the home and the avoidance plan.
Vital signs and airway status where a reaction is present.
The patient’s adherence to the action plan, avoidance measures, and infection precautions.
