Allergies and Reactions (Encounters)

Version 14.8

Overview

In this section, you will find the steps to review and document the patient's medication, non-medication and/or vaccine allergies/reactions.

Reviewing Allergies and/or Reactions

  1. Click on the Allergy/Rxn tab. 
  • The allergies and reactions are listed; you can review through this list.
  • The list is separated by categories of Medication Allergy, Non- Medication Allergy, Adverse Reactions to Rx, and Vaccine Reactions.

In the example below, notice under each category the listing of specific allergies/reactions (e.g. This patient is allergic to Amoxicillin, peanuts, had a reaction to Cefzil, and had an adverse reaction to the flu vaccine. 

Encounter Note: Allergy/Rxn tab

  1. Document that you reviewed this section.
  2. Click on the Green Check Mark button ´╗┐. The information will then auto populate into the text box. This will then be put onto today's note to show that you have reviewed the patient's Allergies and Reaction. See below.

Encounter Note: Allergy/Rxn tab

Adding Allergies or Reactions

  1. Click on the. (See below for a screenshot of the dialogue box that will open).
  2. Click on the dropdown box and select the applicable choice - Medication Allergy, Non_Medication Allergy, Rx Adverse Reaction, or Vaccine Reaction.

  1. Click to document a reaction/allergy to medication.
  • This will open the 'Medication Finder' so you can select the specific medication with dosage which the patient was taking.
  1. Search for the medication. 
  2. Select the correct medication.
  • See below example: Allergy to Omnicef.

  1. Click on the ellipsis to choose the Allergy Group.
  2. Search for the group. In the below example, I want to find 'Cephalosporins' as the allergy group. Therefore searched under 'CEPH' or click on the letter C to pull up all allergy groups with the letter C. 
  3. Select the correct allergy group.
  1. Click on the ´╗┐dropdown to search for the SNOMED code.
  2. If you want to document the symptom, choose the correct symptom from the dropdown menu.
  • You can also type into this field if the dropdown choice did not meet your needs.
  1. Document any notes pertaining to the Allergy/Reaction in the notes text box.

  1. Click Save when complete.