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Enter a Patient's Allergies and Reactions

Version 20.7

Overview

Medication and Non-Medication Allergies are typically entered during the charting of a Visit. However, Allergies and Reactions can also be entered directly into the Patient Chart, outside of the context of a Visit Note. The instructions below assume the Allergies and Reactions are being entered or reviewed during the charting of a Visit.

Review Allergies

  1. From an open Visit Note, click Allergies.
  2. To mark the allergy list as reviewed, click the Mark Reviewed button. The allergy information is displayed in the PMFS History / Meds reviewed text box and is displayed on the patient note.

Note: If the patient does not have Medication Allergies, click the No Med Allergies button, and click OK in the Confirmation dialog box. This sets the indicator that the patient does not have active Medication Allergies.

Add a Non-Medication Allergy

  1. Click the New button. The Allergy/Reaction window is displayed.
  2. Click the drop-down arrow in the Subsection and select NON-MEDICATION ALLERGY.
  3. Select the Status of the allergy. The default selection is Active.
  4. Click the Onset Date field and enter a date or click the drop-down menu and select a date from the calendar. The default selection is the current date.
  5. Click in the Problem field. Enter the name of the problem then press Enter or click the drop-down menu.

NoteIf the problem is not found:

  1. Click the Full Search button.
  2. To expand the search click the Complete radio button.
  3. If the problem is not in the complete list, click the Master radio button.
  4. Once the problem is found, highlight and click the Select button.

  1. Highlight the code and click Select.
  2. Click into the ICD code field. Enter the Description or Code then press Enter or click the drop-down arrow.
  3. Highlight the code and click Select.
  4. (Optional) In the Refer/coord: field, type the name of the specialist or facility that is handling the care for the entered problem. You may also:
  • Click the Address Book button  and search and select from the Address Book entries.
  • Or, click the Coordination of Care button  and select from the list that has been associated to the patient's record.
  1. (Optional) Use the drop-down menus to select Stage/Severity, Quality of life and Symptoms.
  2. (Optional) Add additional comments or pertinent information in the Notes field.
  3. (Optional) Change the Visibility using the drop-down if the privacy level is higher than Any staff Member.

Add a Medication Allergy

  1. Click the New button. The Allergy/Reaction window is displayed.
  2. Click the drop-down arrow in the Subsection and select NON-MEDICATION ALLERGY.
  3. Select the Status of the allergy. The default selection is Active.
  4. Click the Onset Date field and enter a date or click the drop-down menu and select a date from the calendar. The default selection is the current date.
  5. Click into the Medication field and type part or all of the medication and click the ellipses button to search the Medication List.
  6. Highlight the medication from the Matching Favorites tab or the Master List tab.

NoteThe Medication selected populates in the Allergy/Reaction window as the Medication Group. Select any drug form/strength from the Matching Favorites or Master List tabs.

  1. Click the OK button.
  2. Click the ellipses button to the right of the Allergy group field. The E-Prescriber Allergy Data window displays. 
  3. Enter a description in the Allergy Code/Description field and click the Search button. Click the Complete List radio button if the search does not return information.
  4. Highlight the allergy group and click the Select button.

  1. Click in the Problem field. Enter the name of the problem then press Enter or click the drop-down menu.

NoteIf the problem is not found:

  1. Click the Full Search button.
  2. To expand the search click the Complete radio button.
  3. If the problem is not in the complete list, click the Master radio button.
  4. Once the problem is found, highlight and click the Select button.

  1. Highlight the code and click Select.
  2. (Optional) In the Refer/coord: field, type the name of the specialist or facility that is handling the care for the entered problem. You may also:
  • Click the Address Book button  and search and select from the Address Book entries
  • Or, click the Coordination of Care button  and select from the list that has been associated to the patient's record.
  1. (Optional) Use the drop-down menus to select Stage/Severity, Quality of life and Symptoms.
  2. (Optional) Add additional comments or pertinent information in the Notes field.
  3. (Optional) Change the Visibility using the drop-down if the privacy level is higher than Any staff Member.