Any note: how it gets read

Entering an allergy the patient tells you about

What to put in the allergy field so the next nurse doesn't have to wake the patient at 3 a.m. and ask all over again

6 min read built on 0 cases updated 2026-10-30

Written by a med-surg RN, ten years, day shift. Why there is no name on it · How this guide is made

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The patient tells you they're allergic to penicillin, codeine and shellfish. You've got a few minutes and an allergy field that takes one word. Whatever you put there decides what the next nurse, pharmacist or prescriber does. If you write too little, they'll either ignore it or follow it too strictly.

Key points

  • Name the exact substance. Write amoxicillin, not penicillins. Write sulfamethoxazole-trimethoprim, not sulfa. The only exception is when the patient really doesn't know which one it was.
  • Write down what happened to the body: hives, throat swelling, vomiting, a drop in blood pressure. If they can't remember, write that.
  • Add when it happened and how bad it got. Did they need treatment? An ED visit? Epinephrine?
  • Say where you got it: the patient, a family member, an outside record, or a reaction you saw yourself.
  • Ask if they've taken the same drug or a close relative since then with no trouble. Chart the answer.

What to write

How it often gets charted What the next clinician can actually use
PCN allergyAmoxicillin: diffuse hives and lip swelling within 1 hr of first dose, approx 2015. Treated in urgent care with IM injection (pt unsure what). Source: patient.
SulfaSulfamethoxazole-trimethoprim: itchy rash on trunk day 5 of course, approx 2019. No mucosal involvement, no blistering, no hospitalization per pt. Source: patient.
Codeine: allergyCodeine: nausea and vomiting after doses, no rash, no breathing difficulty. Intolerance per pt description. Has taken oxycodone since without problem. Source: patient.
MorphineMorphine: pt reports BP dropped and felt itchy all over after IV dose during surgery, year unknown. Unclear if itching was hives or flushing. Source: patient; no outside record available.
Contrast dyeIodinated IV contrast: wheezing and throat tightness during CT, 2021, received epinephrine in radiology. Source: patient and spouse. Outside records requested.
IbuprofenIbuprofen: pt lists as allergy, describes stomach upset only. Reports taking OTC ibuprofen at home within past year with no ill effects. Pt aware of entry; prescriber notified for review.
Unknown reactionCefazolin: pt was told as a child they reacted to an antibiotic, believes it was this one. Cannot describe reaction. No documentation available. Source: patient (secondhand from parent).

None of these rows decides whether it's a true allergy. That's for the prescriber, the pharmacist or an allergist. What the rows do is give the next person enough to decide without waking the patient up for another interview at 3 a.m.

Template

Allergy entry comment (true allergic-type reaction)

Agent: [EXACT DRUG / FOOD / SUBSTANCE NAME]
Reaction: [WHAT HAPPENED, e.g. hives on arms and chest, lip swelling, wheezing]
Onset: [HOW LONG AFTER EXPOSURE, e.g. within 30 min of first dose]
When: [YEAR OR APPROXIMATE DATE]
Severity / treatment: [e.g. treated with epinephrine in ED / resolved with oral antihistamine / no treatment]
Tolerated since: [RELATED DRUGS TAKEN SINCE WITHOUT REACTION, or "none known"]
Source: [patient / family member: NAME, RELATIONSHIP / outside record: FACILITY, DATE / observed by RN]
Entered by: [NAME, CREDENTIALS], [DATE] [TIME]

Allergy entry comment (side effect or intolerance)

Agent: [EXACT DRUG NAME]
Reaction: [SYMPTOM, e.g. nausea and vomiting / drowsiness / constipation]
No rash, swelling, or breathing difficulty reported by pt.
When: [YEAR OR APPROXIMATE DATE]
Tolerated since: [e.g. has taken oxycodone since without problem / none known]
Source: [patient / family member: NAME, RELATIONSHIP / outside record]
Entered as intolerance per pt description. [PRESCRIBER / PHARMACIST NAME] notified for review on [DATE] at [TIME].
Entered by: [NAME, CREDENTIALS], [DATE] [TIME]

Nursing note when the history is unclear or conflicts with the list

[DATE] [TIME]. Allergy history reviewed with [patient / NAME, RELATIONSHIP].
Pt lists [DRUG] as an allergy. Pt describes reaction as [PT'S DESCRIPTION, or "unable to recall"].
Pt states [he/she/they] [took / did not take] [DRUG OR RELATED DRUG] [WHEN] [with / without] reaction.
Information source: [patient report / family report / outside record from FACILITY dated DATE].
Allergy entry updated with reaction details. Entry not removed.
[PRESCRIBER / PHARMACIST NAME] notified of discrepancy at [TIME]. Response: [WHAT THEY SAID OR ORDERED].
[NAME, CREDENTIALS]

Message to pharmacist or prescriber

Re: [PATIENT NAME], [MRN], room [ROOM].
Pt reports [DRUG] allergy. Described reaction: [REACTION], [WHEN], [TREATMENT NEEDED].
Pt also reports [taking RELATED DRUG on DATE without problem / no known exposure since].
Currently ordered: [DRUG IN QUESTION, DOSE, ROUTE], not yet given.
Requesting review before administration. Allergy entry updated with details above.
[NAME, CREDENTIALS], [PHONE / EXTENSION], [DATE] [TIME]

Words to avoid

Word or phrase Why it hurts Use instead
allergy (with nothing after it)Doesn't say what kind of reaction or how badThe reaction itself: hives, vomiting, throat swelling
reaction or bad reactionCould be anything from mild nausea to anaphylaxisWhat the patient actually felt and what was done about it
unknownLooks like nobody askedPt cannot recall reaction; told by parent as a child
sulfa, PCN, opioidsA class name hides which drug it was and blocks related drugs that may be safeThe specific drug name, or specific agent unknown
severe (alone)Means something different to everyoneThe objective fact: needed epinephrine, admitted, intubated
intolerance (alone)Gets lost or ignoredThe symptom: GI upset, drowsiness, headache
NKDA when you didn't actually askNow silence is a fact the next clinician trustsAsk, then chart; if you couldn't ask, write unable to obtain, pt sedated

A drug name with no reaction

The usual mistake is a drug name with no reaction. Take Codeine with an empty reaction field. Maybe the patient's airway closed. Maybe codeine made them nauseated in 2009. The next clinician can't tell which, so they pick one of two bad options.

They treat it as a real allergy. The patient doesn't get a drug they need and ends up on a second choice. It might work worse, cost more or bring more side effects.

They decide the list is junk. After enough charts with 20 entries that all turned out to be stomach upset, people stop reading. Then the one real anaphylaxis on the list gets overridden with everything else.

Both happen for the same reason: the entry doesn't say enough to sort it. An allergy means the immune system reacted. That's hives, angioedema, wheezing, anaphylaxis, a severe skin reaction. An intolerance is an expected side effect the patient didn't like: nausea, drowsiness, constipation, headache. Chart both. Just chart them so the next person can tell them apart, and what does that is the reaction, the severity and the timing.

The source is the other weak spot. Mom says I'm allergic to penicillin, I don't remember why is useful. But it's a different kind of fact from I got hives and my lips swelled two hours after the first dose, and urgent care gave me a shot. If the chart doesn't say which one you heard, the next reader can't weigh it.

Bottom line

A drug name with no reaction next to it is a question you're leaving for the next nurse. Write down what happened, when, how bad it was, and who told you.

Official guidance

What this rests on

No published decision turned up for this question. We looked, and the searches are in the record. So this article stands on published guidance and on how the question is asked on the floor, not on a court opinion. That is a weaker footing than the rest of the guide, and you should know it before you rely on it. The decisions behind the other articles are all in one place.

From nurses online

Quoted as written. Opinion, not a source.

Other guides

Advice, not law.