Record an allergy
Overview
This flow describes how to record an allergy or intolerance for a patient during an encounter in Care.
Pre-requisites
- The patient has an open encounter at the facility, and you record the allergy from that encounter.
- The encounter is not Completed, Cancelled, Discontinued, or Entered in Error. In these states, all add and edit controls are read-only.
- You have the permissions listed below.
Permissions
| Permission | Access |
|---|---|
| Can submit questionnaire about patient encounters | Lets you submit the allergy screen of the encounter. |
| Can Update a Patient's data | Lets you record a new allergy for the patient. |
| Can view clinical data about patients | Lets you see the allergies of the patient. |
Steps
1. Open the allergy screen
Open the encounter. Go to the Overview tab. Select the Allergy quick action.
You can also press the keyboard shortcut a on any encounter screen.
You can also find the Allergies section and select the edit (pencil) icon.
The allergy screen shows the allergies that the patient already has.
2. Search for the substance
Select Add Allergy. For each further allergy, the control reads Add another Allergy.
Type the name of the substance that the patient reacts to.
The results come from a standard SNOMED CT allergy terminology.
Note: Your administrator sets the clinical terminology for your deployment. Your administrator can also change it.
3. Select the term
Select a term. A new row appears with these default values:
| Component | Default |
|---|---|
| Category | Medication |
| Criticality | Low |
| Status | Confirmed |
| Clinical Status | Active |
4. Change the values
Change the values of the row if you need to.
| Component | Options |
|---|---|
| Category | Food, Medication, Environment, Biologic |
| Criticality | Low, High, Unable to Assess |
| Status | Unconfirmed, Presumed, Confirmed, Refuted |
| Occurrence | Any date up to today |
To change the clinical state, open the more-options (⋮) menu of the row. Select Mark Inactive or Mark Resolved.
Note: Care does not offer Entered in Error for a new allergy.
5. Add a note
To add a note, open the more-options (⋮) menu of the row. Select Add notes. Type the note.
Select Show notes to open the note text. Select Hide notes to close the note text.
6. Add more allergies
Repeat from step 2 for each further allergy.
7. Submit
Select Submit.
Expected Outcome
- Care shows the confirmation "Questionnaire submitted successfully".
- Care returns you to the Overview tab of the encounter.
- The allergy appears in the Allergies section of the encounter Overview tab.
- The allergy appears in the allergy history of the patient.
When the patient has no allergy, the encounter shows no Allergies section.
Related
Concepts:
Flows: