Entering Allergies from the Cover Sheet Tab

You can enter a new allergy or adverse reaction from the Cover Sheet tab in either of two ways:

· Right-click anywhere within the Allergies/Adverse Reactions pane.

· Click to display more information about a causative agent listed in the Allergies/Adverse Reactions pane.

Method One

Take the following steps to enter new allergies using the first of the two methods mentioned above:

1. Move your mouse arrow to a location anywhere within the Allergies/Adverse Reactions pane.

2. Right-click to display a pop-up menu.

3. From this menu, select Enter new allergy. CPRS displays the Allergy Reactant Lookup dialog.

4. In the Enter causative agent for Allergy or Adverse Drug Reaction field, type the first three characters (minimum) of the causative agent's name.

5. Select Search. CPRS displays a list of possible matches.

6. If the causative agent you typed does not match any of the agents currently available for your site, CPRS displays the Causative Agent Not On File dialog, from which you can select one of the following three options:

Note: The patient's chart will not be updated unless you choose a causative agent that is on file.

a) Yes: Use this option to request that the causative agent be added for your site's ALLERGIES file. When you click Yes, CPRS displays the Enter Optional Comments dialog, which enables you to type additional comments (optional), such as the signs or symptoms that occurred as a result of contact with this causative agent, or whether you observed these symptoms firsthand. After you type your comments, click Continue. CPRS then sends to members of your site's GMRA Request New Reactant mail group a message that includes the following items:

· The causative agent you attempted to enter

· The name of the patient for whom you attempted to make this entry

· Your name, title, and contact information

· Your comments

Note: When the bulletin is sent, a message such as the following will display. This message also informs the user that the allergy was NOT entered into the patient's record.

Members of your site's GMRA Request New Reactant mail group will review this message and, if appropriate, add the causative agent to your site's ALLERGIES file.

Note: If your site's IRM staff has not yet added members to your site's GMRA Request New Reactant mail group, CPRS displays the following message: Mail group GMRA Request New Reactant has no members - Contact IRM..

b) No: Clicking No enables you to try an alternate spelling or trade name for your causative agent, or to type another causative agent.

c) Cancel: Use this option if you want to cancel your allergy order.

7. If the causative agent you typed matches an agent that is currently available for your site, select the agent. (Click + to expand a heading.)

Note: With CPRS GUI 24 or later, you may not add free-text causative agents. If you select an item under the "Add new free-text allergy" heading, CPRS displays the Causative Agent Not On File dialog.

8. Select OK.

The Enter Allergy or Adverse Reaction dialog appears.

Note: You can view a patient's current allergies or adverse reactions by selecting the Active Allergies button. Also, the user previously could change the Originator, but this is no longer allowed. The originator is the user logged in.

9. Use the Observed or Historical option button to indicate whether the entry is for an observed or historical allergy, respectively. (If you point your mouse at either of these option buttons, CPRS displays a hover hint that explains the observed and historical options.)

Note: Observed or Historical used to have a default, but the user must now select the appropriate choice. CPRS does not allow you to select future dates for observed allergy/adverse reaction entries.

Note: When you select Observed for a drug reaction, CPRS generates a Progress Note. Once this note is signed by the user entering the allergy or by an administrative update user, the note will be viewable by all users.

10. Select the Nature of Reaction (Allergy, Pharmacological, or Unknown).

The Nature of Reaction can be Allergy, Pharmacologic, or Unknown. An allergic reaction occurs because the patient is sensitive to a causative agent, regardless of the amount the patient is exposed to. A pharmacologic (non-allergic) reaction occurs when the patient is sensitive to an agent under certain conditions, such as exposure to a large amount. Unknown is provided if you are not sure what Nature of Reaction (mechanism) to enter.

Note: Allergies are a subset of adverse reactions. All allergies are adverse reactions, but not all adverse reactions are allergies.

11. If you are entering an observed allergy, use the Reaction Date/Time and Severity boxes to select a reaction date, time, and severity. (The Severity box is not visible for historical allergies. If the Severity box is visible, CPRS displays a ? button at its side. If you select this button, CPRS displays text explaining severity selections.)

12. Using the Signs/Symptoms box, select one or more signs or symptoms. The signs and symptoms you select appear in the Selected Symptoms pane.

Note: Signs and symptoms must be selected from the list. Users cannot enter free-text entries.

13. To associate a date and time with a symptom (optional), click to select the symptom in the Selected Symptoms pane.

14. Select the Date/Time button located below the Selected Symptoms pane. CPRS displays the Select Date/Time dialog, from which you can select the date and time that the symptom first appeared.

Note: If you mistakenly enter a sign or symptom but have not yet accepted it by selecting OK, select the symptom in the Selected Symptoms pane and select the Remove button located beneath the pane.

15. Type comments for the allergy in the Comments text box.

16. If you have marked the allergy or adverse reaction on the patient's identification (ID) band (or if you know that someone else has), select the ID Band Marked check box.

Note: CPRS activates the ID Band Marked check box only for inpatients and then only if your site's IRM staff has set a parameter indicating that your site wants to track this information. Depending on whether your IRM staff has set related parameters, if you do not select activated ID Band Marked check box, the system may send a bulletin notifying a mail group that the patient's allergy or adverse reaction is not marked on his or her ID band.

17. Select OK.

CPRS displays the newly entered causative agent in the Allergies/Adverse Reactions pane. If you click on the causative agent, CPRS displays all of the information you just entered about the associated allergy or adverse reaction. CPRS also displays the letter A (for allergies) on the Postings button and the word Allergies in the Postings pane. If you click the word Allergies in the Postings pane, CPRS displays selected information about all of the patient's active allergies and adverse reactions, including the allergy or adverse reaction you just entered.

Method Two

Take the following steps to enter a new allergy using the second of the two methods mentioned above:

1. Select a causative agent listed in the Allergies/Adverse Reactions pane. CPRS displays a dialog that includes details about the allergy or adverse reaction associated with the selected causative agent. The dialog also includes four buttons.

2. Select the Add New button.

CPRS displays the Allergy Reactant Lookup dialog.

3. Follow steps 4 through 17 of the instructions for entering allergies using the first method. CPRS displays the newly entered causative agent in the Allergies/Adverse Reactions pane. If you click on the causative agent, CPRS displays all of the information you just entered about the associated allergy or adverse reaction. CPRS also displays the letter A (for allergies) on the Postings button and the word Allergies in the Postings pane. If you click the word Allergies in the Postings pane, CPRS displays selected information about all of the patient's allergies or adverse reactions, including the allergy or adverse reaction you just entered.