ATI TEAS (Test of Essential Academic Skills) Version 7ReadingHard
A medical assistant is reviewing a new patient's intake form. The patient indicates they have 'no known drug allergies (NKDA).' However, in the past medical history section, the patient listed 'rash and swelling after taking penicillin' five years ago. Which of the following is the most appropriate action for the medical assistant to take based on this discrepancy?
- AUpdate the allergy section to 'Penicillin allergy: rash, swelling' and notify the physician.
- BDocument 'NKDA' as stated by the patient and proceed.
- CAsk the patient if they are currently taking penicillin.
- DIgnore the discrepancy, assuming the patient has outgrown the allergy.
Show answer & explanationAnswer & explanation
Correct answer: A. Update the allergy section to 'Penicillin allergy: rash, swelling' and notify the physician.
This is a critical discrepancy related to patient safety. A documented allergic reaction, even if the patient states 'NKDA,' must be clarified and recorded accurately. Notifying the physician ensures they are aware of the potential allergy before prescribing medications. Assuming the patient has outgrown it or ignoring it could lead to a severe adverse reaction.
Why the other options are wrong
- B. Documenting 'NKDA' despite conflicting history is unsafe and could lead to severe allergic reactions.
- C. Asking if they are currently taking penicillin is irrelevant to the allergy status itself. The priority is to record the past reaction and alert the care team.
- D. Assuming an allergy has been outgrown without medical confirmation is dangerous and medically irresponsible.
Resolving Patient Information Discrepancies
When patient-reported information contradicts documented history, especially regarding allergies, it requires immediate clarification and accurate updating of the record to ensure patient safety.
- Patient safety is paramount.
- Always clarify conflicting information.
- Document accurately and notify care team.
Memory trick: Conflicting allergy notes mean STOP, CLARIFY, and REPORT.