Medical History: Allergy List Medical History: Allergy List
The Allergy List allows you to view, add, remove, or edit a patient's list of allergies and sensitivities. The following topics are discussed on this page. Use the links to jump to the desired subject:
To flag the patient as "No Known Allergy"
To flag the patient as "Allergy Unassessed"
To generate CCD (Continuity of Care Document)
To verify allergy information (No Change)
To access the Allergy List window, use one of the following methods:
(Preferred method) From the Hospital Main page, use the Select button to select the appropriate patient using the drop-down list. Then, click the Allergy button. The Allergy List page is displayed.
OR
Click the Allergy button on the Hospital Main page. The Patient Search box is displayed. Begin typing the patient information. See Selecting Patients for additional details on using this feature.
Once the patient is selected, the patient's basic episode information is displayed in the yellow bar at the top of the screen, including: patient name, DOB, and medical record number. You also have access to the Quick view from the yellow bar. The Quick view is accessed by clicking the green arrow button. See also Quick View.
Upon accessing the Allergy List, active allergies are displayed according to severity with the most severe listed at the top and then alphabetically. To change the view, use the Sort drop-down list to select one of following sort options: Severity, Alphabetical, Type, or Verification date desc. Check the Show Inactive box if you also want to see discontinued allergies.
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Free text allergies, allergies that have been typed in that do not match an item in the allergy database, are flagged with a red triangle in the left-most column of the display. Free text allergies are unable to be used for interaction checking. |
The No Known Drug Allergies, No Known Food Allergies, and No Known Environmental Allergies options are used when the patient has no known allergies to drugs, food, and/or environmental allergens.
Select the appropriate option: No Known Drug Allergies, No Known Food Allergies, or No Known Environmental Allergies radio buttons at the top of the window. The No Known window is displayed. If the No Known Drug Allergies, No Known Food Allergies, or No Known Environmental Allergies radio buttons are not displayed, there are allergies already entered on the patient's record. To get the option to display again, you must remove any associated patient allergies from the list.
In the Source field, use the drop-down list to select the source of information.
In the Activated Date, enter the date in which the "No Known" status is activated. Usually, the current date.
Click Save. You are returned to the Allergy List where the No Known Drug Allergies, No Known Food Allergies, or No Known Environmental Allergies text is displayed.
Edit and history buttons are available for the No
Known allergy type. The edit function is used to change the source. See
To edit an allergy for additional information.
When you add allergies for a patient with a No Known Allergies status,
the following status change verification message is displayed: This patient's allergy status is No Known Allergy,
the action selected will change the status. Would you like to continue?
Click Yes. Then, click Save
to proceed. The Add Allergy window is displayed. See To
add an allergy for detailed instructions.
The Allergy Unassessed option is used when you are unable to assess the patient for allergies.
Select the Allergy Unassessed radio button at the top of the window. The Unable to Assess window is displayed. Note: If the Allergy Unassessed radio button is not displayed, there are allergies already entered on the patient's record. To get this option to display again, you must remove any patient allergies from the list.
In the Reason field, use the drop-down list to select the reason you were unable to assess the patient's allergies. To enter a reason that is not in the list, select the Other (See Notes) option. An Other Reason field is enabled. Type the reason in the field.
Click Save. You are returned to the Allergy List with the Type displayed as Allergy Unassessed.
Edit and history buttons are available for the Unassessed
allergy type. The edit function is used to change the reason. See To
edit an allergy for additional information.
When you change the status for a patient with an Unassessed status (either
by adding an allergy or changing to a No Known status), the following
status change verification message is displayed: This
patient's allergy status is Unassessed, the action selected will change
the status. Would you like to continue? Click Yes.
Then, click Save to proceed.
The Add Allergy window is displayed. See To add an
allergy for detailed instructions.
Click Add Allergy located at the upper or lower right hand corner of the window to add an allergy to the patient's current allergy list. The Add Allergy window is displayed.
In the Type field, select Allergy or Sensitivity as the allergy type.
In the Allergen Description field, begin typing the allergy description. Type at least 3 characters to display the most accurate results, including medications. The search will display possible matches found in the description as you type in two categories: Medispan and Hospital. You can continue typing to narrow down the list. Highlight and click the desired allergy or sensitivity as displayed in the drug database; or, if you cannot locate the appropriate item, you can enter a free-text description (SEE NOTE).
If you enter the allergy as free-text, a message is displayed alerting you that interaction checking will not occur against this allergy. Free-text allergies are also flagged in other windows and reports to show that it was a free-text entry. On the Allergy tab, allergies/sensitivities that have been entered as free text display a red triangle in the left-most column of the display.
In the Severity field, use the drop-down list to select Unknown, Mild, Moderate, or Severe.
In the Reaction section, check the following boxes that describe the patient's reactions:
Anaphylaxis
Gl Symptoms
Periorbital swelling
Rash
Other
If you check Other, also enter a description of the reaction in the space provided.
In the Source field, use the drop-down list to select the source of the allergy, e.g. father, mother, sister, etc.
In the Activated Date, enter the date in which the allergy is activated. Usually, the current date.
Click Save and Add More to save the allergy and remain in the window to add additional allergies, or click Save and Close to save the allergy and return to the Allergy List. The new allergies are included in the list.
Click the Edit button for the allergy you want to edit. The Edit Allergy box is displayed.
Edit any of the fields as needed. See To add an allergy above for field descriptions. Note: You cannot change the allergy description.
In the Reason for Edit field, use the drop-down list to select a reason for the edit. To enter a reason that is not listed, select Other (See notes) from the list and type in the required free-text reason in the Other Reason field.
Click Save to save your changes and return to the allergy list, or click Close if you want to cancel your changes. An audit trail of the changes can be viewed in the allergy history.
Click the Remove button for the allergy you want to discontinue. The Discontinue Allergy box is displayed.
The Discontinue Date defaults to the current date. Modify, if necessary, using the calendar button next to this field.
In the Reason for Discontinue field, use the drop-down list to select a reason for removing the allergy from the patient's allergy list.
Click Save to continue. You are returned to the allergy list with the allergy removed from the active list (SEE NOTE).
Discontinued allergies can be viewed by checking the View Inactive box. Click the History button, located next to the inactive allergy, to view the audit trail (history) including the reason for discontinuation.
Allergy history allows you to view the current details of a particular allergy and all historical changes and verification information for the allergy.
Click the History button for the allergy. The Allergy History window is displayed.
The Current section contains the current details of the patient's allergy, including allergy type, description, severity, reaction, user and date of last verification, source of the allergy (e.g. father), and status.
The History section contains a list of all changes that were made to the allergy components in descending order by date, including the action taken (e.g. Edit, Remove), date, time, and user ID of the edit, reason for the edit, and all components that were changed, including the original and new values.
The Verification section contains a list of date/times that the allergy was reviewed, and the user ID of who performed the verification.
Click Back to return to the Allergy List.
The CCD is a clinical summary document generated from the patient's clinical information, including insurance providers, advance directive information, problem list, and medication information. This document opens in a new browser tab, where it can be e-mailed, saved, and/or printed to the patient and/or another healthcare provider. To generate the CCD, click the Generate CCD button.
The No Change option allows you to indicate that you have reviewed and verified that all allergy information is correct as required before placing orders.
Click No Change located at the upper or lower right-hand corner of the window.
A message box is displayed with the message, Would you like to mark all allergies as being reviewed and verified? Select Yes to indicate you have reviewed and verified all allergy information, and click Save; or select No or click Close if you do not want to perform the verification at this time. Once reviewed, the date and time displayed in the Last Reviewed field is updated.
Using the Shortcut Tabs: Search, Demographics, Summary, and Allergy |