Background
Add Allergies and Adverse Reactions from the Common List
Add Allergies and Adverse Reactions not listed in the Common List
Enter No Adverse Reactions
Add Allergies and Adverse Reactions without documenting type of reaction
Allergies/Adverse Reactions display in the Medical Record
Background
Improvements have been made to adding allergens to the patient’s medical record. Whenever possible, Profile EMR recommends adding the allergy or adverse reaction through the Adverse section of the Medical Record from the Common list of allergens.
Add Allergies and Adverse Reactions from the Common List
The Common list has been populated with the top 20 drug allergens and are correctly linked to the to the right allergen group in the First Databank Formulary.
1. From Actions Panel in in New Encounter , click on Adverse and review the Common list
2. From the Common allergen list
a. Single click over the medication name (to highlight)
b. Click the Add button
c. The pop-up Problem – Adverse will appear. In the Nature field, click the ellipse.
d. Click the selected reaction from the Adverse Reaction Nature list and then OK
Note: EMR forces you to select a reaction from the list. If it is not listed, you must select Other and then add the specifics in the free text field beside it.
Add Allergies and Adverse Reactions not listed in the Common List
If the allergen is not listed in the Common list, then then you will have to add it from the formulary.
1. From the Actions Panel in New Encounter, click on Adverse and then the New button
2. A pop-up will appear called Problem - Adverse
a. Type the drug name
b. Pick dosage from the list and double click on it
c. Another pop-up will appear called Rx Item Groups. The allergen group(s) will be listed – click on the desired group
d. Click OK
Note: There are times when two allergen groups are displayed – select as per clinical judgement
e. In the Nature field, click the ellipse
f. Click the selected reaction from the Adverse Reaction Nature list and then OK
Note: If you prefer the Description field to display the drug name versus the allergen group, simply remove it and type in the name e.g. Ativan rather than Benzodiazepine. It will still be correctly link to the correct group.
Enter No Adverse Reactions
1. From Actions Panel in New Encounter, click Adverse
2. On the far right screen, click the checkbox beside No Adverse Reactions
Alternatively, No Adverse Reactions can be entered from the Clinical Details Panel:
Add Allergies and Adverse Reactions without documenting type of reaction
EMR forces you to select a reaction from the list. If it is not listed, you must select Other and then add the specifics in the free text field beside it, type Unknown if not sure about the nature of reaction
Allergies/Adverse Reactions display in the Medical Record
The entered allergies and adverse reactions will display throughout the Medical Record. The main sections are located below the yellow bar in the Adverse reactions window; in the Adverse section; and in the Problems list.