Allergies
Allergies History
1. Allergy History: Here you can view the patient's current allergies.
2. Filters: The top filter will allow you to view the history by Active, Expired or All. The bottom filter allows you to view by Most recent, Past 6 months or Past 1 year.
3. Action: This is where you can Edit or Expire if there are changes to the patient's allergies.
Allergies Input
1. Allergy Input: Here is where you will be able to enter a new allergy to the patients’ chart.
2. Allergen Type: Depending on which option you select the fields to complete will be slightly different. The options are allergen, medication or no known allergy. Read below to learn more.
3. Severity: You will select how severe the patient's reaction is to the allergy; life threatening, low, moderate, severe, or unknown.
4. Reaction: Here you will select what type of reaction the patient has to the allergy; anaphylaxis, itching and wheezing are a few examples.
5. Allergen: This is specific when you select Allergen from the type drop-down. You will select the allergen from the list the patient has an allergy to.
6. Notes: Here you can enter additional notes regarding the allergy for other staff members to view.
7. Submit/Reset: Reset will remove all the entered fields, this is helpful if you are editing but want to enter a new allergy. Submit will save and input into the patient’s history.
Medication Allergy Input
1. Allergy Input: Entering a medication allergy will be very similar as entering an allergen. You will select Medication from the type drop-down.
2. Prescription: You will select the medication the patient is allergic to from the drop-down. If the medication is not listed, you can use the search function to select it.
3. Find: Here you can search for a medication. If the medication you are looking for is not in the Prescription list, you can search by keywords to locate the medication. When you click find, a results table will populate where you will need to select the medication (regardless if the medication is the only one in the list).
4. Notes/Submit: You can add additional notes if necessary and submit to the patient's chart.
No Allergy Input
1. Allergy Input: If the patient has no known allergies you will select this from the drop-down.
2. Allergy Type: Once selected this will trigger the severity and reactions to default to N/A since they are no longer applicable. For example, No Known Allergies.
3. Submit/Reset: You can add additional notes if necessary and submit to the patient's chart.
CONFIDENTIAL AND PROPRIETARY INFORMATION - NOT FOR DISTRIBUTION Copyright © 2020 Health Information Management Systems, LLC
Related Articles
Patient Valuables
Patient Valuables Important: Before recording patient valuables, the patient must already have an admission created in the Inpatient or Residential module. Video Tutorial: Getting There: The Patient Valuables page is located in both the Residential ...Patient Request
Patient Request Date: This will default to Today’s Date, clicking the calendar icon will allow you to make any adjustments to the service date. Time: Here you can select the time of the request. Clicking on the clock icon will allow you to choose ...Vitals
Graph/Outcomes 1. Graph/Outcome: This section will automatically graph the Vital History allowing you to see trends in inpatient data. 2. Graph / Outcomes: The selected tab will have a dark blue background. Clicking on Outcomes would switch the ...Prescription Administration Sheet
Getting Started in Prescription Admin Sheet 1. Provider: This should display your name to prescribe medications. 2. Sending Site: This should display the site the patient is being seen. 3. Provider's DEA Number: This should display your DEA ...Nursing Assessment
Getting Started in Nursing Admission Assessment Category or All: You are able to change the view of the PCP chart to either be category based as the image above or you can view All sections of the PCP note in a vertical format. ' Chart Detail ...