How To Document Allergies in EMR

Documenting allergies in your EMR is crucial for providing safe and effective care. The following steps outline the process for documenting a patient’s allergies accurately :

Steps to Document Allergies Details in EMR:

Step 1: From the main dashboard, click on “Patient Tab”.

Open

Step 2: In the Patients Tab:

• Search and select the patient’s name.

Open

Step 3: Select “Consults”. 

Step 4: Click on “View”.

Step 5: Select “Diagnosis Info”.

Step 6: Click on “Allergies” to document the patient's allergy information.

Step 7: In the “Search Allergies” box, enter the name of the allergy.

• You can type specific allergens (e.g., pollen, peanuts, penicillin) or select from a list of known allergies.

Step 8: Select the allergy severity level from the available options:

• Mild

• Moderate

• Severe

Step 9: You may provide additional details about the allergy in the “Comments” box.

• Include any relevant notes, such as the type of reaction (e.g., rash, anaphylaxis) or any past treatments or interventions.

Step 10: Click “Save Allergy” to store the allergy information in the EMR.

These steps ensure that the patient’s allergy details are recorded accurately in the EMR, helping to facilitate safe and informed care decisions.