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”.

Step 2: In the Patients Tab:

Search and select the patient’s name.

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.

The allergy data is received from FDB, and we are not able to manually add new allergy entries to that database. Each allergy entry has a unique ID, which is used to support drug-allergy interaction checking through Surescripts.

Examples:

For an SSRI allergy, FDB may not show “SSRI” as a direct allergy term because allergies are typically indexed by the specific medication or ingredient rather than the broader drug class. You may want to try searching for the specific SSRI medication the patient reacted to, such as:

Sertraline / Zoloft
Fluoxetine / Prozac
Escitalopram / Lexapro
Citalopram / Celexa
Paroxetine / Paxil
Fluvoxamine / Luvox
Vilazodone / Viibryd
Vortioxetine / Trintellix

For chlorine allergy, FDB may not show “chlorine” as a standard allergy term because it is often documented as a chemical sensitivity or irritant exposure rather than a medication allergy. You can try searching for related terms such as:

Sodium hypochlorite
Hypochlorite
Bleach
Chlorhexidine, only if the reaction was specifically to chlorhexidine