Add an Allergy to a Patient's Chart

When adding allergies to a patient's chart, you have the ability to indicate a specific Allergy, No Known Allergies, or No Known Drug Allergies. Use the following steps to add an allergy to a patient's chart.

1. Open a patient's chart note.
    

2. In the chart note, click the ALRG button, and then select No Known Allergies, No Known Drug Allergies, or Add/Modify Allergies.
   
   If the Add/Modify Allergies option is selected, go to step 3.
   
   When the No Known Allergies or No Known Drug Allergies option is selected the system will automatically update the Face Sheet with a "No Known Allergies” or “No Known Drug Allergies” entry, the history tab and the audit trail will also list applicable entries for this event, and the chart note will indicate that there are no known allergies. You can skip the following steps if either the No Known Allergies or No Known Drug Allergies is selected.
   
   
   
   
   NOTE: If the patient already has allergies configured, and the No Known Allergies or No Known Drug Allergies option is selected, the system will generate a warning indicating these allergies will be overridden and removed if you choose to proceed.
   
   If you click the Yes button the system will remove all allergy information and the chart note, Face Sheet, History tab, and Audit Trail will contain applicable entries for the allergies removed and the new option selected.
   
   If you click the No button, you will return to the patient's chart.
   
   
   
    

3. In the Active Allergies dialog, click the Add button.
   
   
   
    

4. In the Select Allergy dialog, select the Allergy Type (Drugs, Groups, or Ingredients) for the type of allergen you want to search for, then you can select the applicable Search Type (Contains, Equals, or Starts With), then in the description field type a few letters of the allergy you want to add, and then click the Search button. When searching for an allergy you can be as specific or as vague as you like, however, the search results will be determined by the specificity of your search.
    

5. The system will return applicable drugs, drug groups, and ingredients that match the search criteria. You can change the Allergy Type to Drugs to view specific drugs, Groups to view drug groups, or Ingredients to view specific drug ingredients, and the system will display the applicable allergens based on type selected.
    

6. Once the applicable allergen has been located, highlight that Allergen, and then click the Select button.
   
   NOTE: Once you click the Select button, if the patient had No Known Allergies or No Known Drug Allergies configured, those entries will be automatically be removed and updated in chart note. Likewise, applicable entries will be made in the patient's Face Sheet and  History tab, and the Audit Trail will also be updated with an applicable entry.
   
   
   
    

7. If there are any interactions present with this allergen and any drugs that are currently prescribed, this system will generate an Interactions Present warning that will outline any possible adverse interactions, thereby allowing you to discontinue a drug or change the drug being prescribed. When finished viewing the interaction information, click the OK button.
   
   NOTE: You can also view any drug to allergy interactions for any medications that have been, or are currently, prescribed for the patient by clicking the button to the left of the applicable medication in the patient's facesheet, and then clicking Medication Interactions (RxINT). If there are any interactions or warnings, an Interactions Present dialog will appear outlining any possible adverse interactions.
   
   
   
    

8. Once the Allergy has been added, click the Add button in the  Reaction SNOMED field to configure applicable SNOMED codes for any reactions that the patient has to the allergen.
   
   
   
    

9. In the Select SNOMEDs dialog the system will default the typical allergic reactions and their accompanying SNOMED codes. You can check the applicable reactions as needed. If you check the Reaction option, all of the reactions will be selected. If you do not see the applicable reaction or SNOMED code, you can click the Search button and search for specific SNOMED codes as needed.
   
   When finished selecting the applicable SNOMED codes, click the OK button.
   
   
   
    

10. If SNOMED codes were selected in the Reaction SNOMED field for the allergy, the descriptions for the selected SNOMED codes will automatically be added, or appended if there is existing information, to the corresponding Reaction field. You can enter or modify the information in this field, as needed.  
     

11. Select the Severity of the allergic reaction (Fatal, Life threatening severity, Mild, Mild to moderate, Moderate, Moderate to severe, and Severe).
     

12. Check the Note Allergy option if you want the allergy to print in the chart note.
     

13. Check the Note Reaction option if you want the reaction to print in the chart note.
     

14. If the allergy information has been reviewed, click the Review button, or, if you are reviewing all of the applicable allergens, click the Review All button. The date of the note will appear in the Reviewed column for reviewed allergens. Likewise, when allergies are reviewed the review date appears in the Face Sheet beside the allergy and the History tab is updated with this information.
     

15. Check the Display results in list format box if you want the allergy information to appear as a list instead of in paragraph format.
    
    
    
     

16. When finished, click the OK button. The allergies will only be added to the patient's chart after the OK button has been clicked. If you close out of the dialog, or click the Cancel button, the new entries will not be added to the patient's chart.