Enter a Patient's Allergies and Reactions

OP sets all defaults to share all information. Any individual decisions by Practice-users to restrict information sharing (access, use, or exchange) are the responsibility of the Practice in the implementation of its 21st Century Cures Act Information Blocking policies and procedures for its Practice and patients.

Version 20.18

This documentation applies to On-Premise and Cloud Practices that have been updated to OP 21.0 If your Practice has not yet been updated to 21.0, refer to the documentation located in the Version 20.18 tab above. To check your OP version, go to Help tab > About and refer to the Build Number field.

About

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 steps 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 to confirm. 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 Subsection drop-down and select NON-MEDICATION ALLERGY.
  3. Select the Status of the allergy. The default selection is Active.
  4. Click in the Onset Date field and enter a date or click the drop-down 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 and search for the problem.
  6. Highlight the code and click Select.
  7. Click in the ICD code field. Enter the Description or Code then press Enter or click the drop-down and search for the ICD code.
  8. Highlight the code and click Select.
  9. (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) Enter the symptom(s) and associated severity.
  1. Click the Symptoms/severity ellipsis button.
  2. In the Symptoms window, click Click here to add a new symptom, type the symptom and press Enter.
  3. Select the symptom from the list or click the Full Search button and search for and select a symptom.
  4. Click in the Severity field and use the drop-down to select the severity of the symptom from the list.
  5. Click the Save button.
  6. Repeat the above steps to add additional symptoms and their severity.
  7. Once all entries are made, click the Exit button.
  1. (Optional) Click the Quality of life drop-down and select from the list.
  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.
  4. Click the Save button.

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 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 Medication field and type part or all of the medication and click the ellipsis 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 ellipsis button to the right of the Allergy group field.
  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.
  5. Click in the Problem field. Enter the name of the problem then press Enter or click the drop-down and search for the problem.
  6. Highlight the code and click Select.
  7. (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) Enter the symptoms and severity.
  1. Click the Symptoms/severity ellipsis button.
  2. In the Symptoms window, click Click here to add a new symptom, type the symptom and press Enter.
  3. Select the symptom from the list or click the Full Search button and search for and select a symptom.
  4. Click the Severity field, and use the drop-down to select a severity from the list.
  5. Click the Save button.
  6. Repeat the above steps to add additional symptoms and their severity. 
  7. Once all entries are made, click the Exit button.
  1. (Optional) Click the Quality of life drop-down and select from the list.
  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.
  4. Click the Save button.
Version 20.17

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 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 ellipsis 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.