Assess allergic/immune status in the context of the skilled reason and document the judgment:
Documented allergies and any reaction (timing, trigger, severity — from mild urticaria to anaphylaxis with airway/circulatory involvement), and the response to treatment.
For immunosuppression: the agent and the infection-precaution plan, and infection surveillance remembering the blunted response (a low-grade fever or subtle change may be the only sign); for IVIG/immunotherapy: the administration and reaction monitoring.
Signs of a severe drug reaction (spreading rash, mucosal involvement, blistering, fever) and autoimmune-flare activity where relevant.
MDS-supportive data
IVIG/IV medication and isolation are coded in MDS Section O0110, immunosuppressants in Section N, and the immunologic diagnosis or drug allergy in Section I. The record must document the allergic/immune assessment, the immunotherapy and monitoring, and the precautions so the MDS is supported.
