Flows/Record an allergy

flowclinicalCARE 3.1+

Clinical

Concepts

Patient

Encounter Care team Condition Allergy & Intolerance Observation Diagnostic Report Service Request Specimen Consent Clinical Notes

Questionnaire Response

Flows

Search for a patient

Register a patient View a patient's profile Update patient details Manage patient identifiers Manage patient tags Mark a patient as deceased Manage patient users View a patient's appointments and tokens Create an encounter Update encounter details Assign an encounter location Manage the encounter care team Manage encounter departments Manage encounter tags Discharge a patient Complete an encounter

Restart an encounter

References

Patient

Encounter Care team Condition Allergy Intolerance Observation Diagnostic Report Consent Notes Specimen Service Request

Questionnaire Response

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.

Clinical

Concepts

Patient · Encounter · Care team · Condition · Allergy · Observation · Dx Report · Service Request · Specimen · Consent · Notes · Q. Response

Flows

Search · Register · Profile · Update · Identifiers · Tags · Deceased · Users · Appointments · Create Encounter · Update Encounter · Location · Care Team · Departments · Tags · Discharge · Complete · Restart

References

Patient · Encounter · Care team · Condition · Allergy · Observation · Dx Report · Consent · Notes · Specimen · Service Request · Q. Response

Related

• Concept: Concepts/Allergy & Intolerance

Open Healthcare Network's flagship product: an open-source, FHIR-native electronic medical record (EMR) and healthcare operating system.

A comprehensive clinical terminology used to code diagnoses, findings and procedures.