Allergy Entry in Powerchart

PowerChart Allergy Entry

Table of Contents

ALLERGY ENTRY ...... 2 Accessing the Add Allergy Window from the Allergies section of the Menu ...... 2 Accessing the Add Allergy Window from the Demographic Bar ...... 2 Accessing the Add Allergy Window from the PAL ...... 3 Accessing the Add Allergy/Adverse Effect Window from PowerForms in Ad Hoc Charting ...... 3 Entering Allergy Information ...... 4 Common Substance, Food, and Environmental Lists ...... 5 No Known Allergies ...... 5 No Known Medication Allergies ...... 6 Allergy substance is not available in the search tool ...... 7 Unable to obtain allergy information ...... 8 Canceling an allergy ...... 8 Modifying an allergy ...... 8 My Favorites: ...... 8 Viewing Current Allergies only ...... 9 Allergy Verification Process...... 9 Tips ...... 10

Revised April 2016

1 ALLERGY ENTRY

Allergies can be entered multiple ways in PowerChart and FirstNet: from the Allergies section of the Floating Menu, from the Demographic Bar, and from Tracking Lists. They can also be entered via the Admission tasks on the PAL and from PowerForms in Ad Hoc charting. All methods use the Add Allergy / Adverse Effect window.

Accessing the Add Allergy Window from the Allergies section of the Menu 1. Click Allergies on the Floating Menu.

2. Right click the white section of the Allergies window. 3. Select Add New. 4. Select Drug Allergy. 5. The Add Allergy/Adverse Effect window opens. OR 1. Click on the + Add icon on the Floating Menu. 2. The Add Allergy/Adverse Effect window opens.

Accessing the Add Allergy Window from the Demographic Bar 1. Click the Allergies section of the demographic bar. The bar will either display Allergies Not Recorded, No Known Allergies, No Known Medication Allergies with associated other identified allergies or the patient’s drug allergies.

1. The Custom Information Allergy window opens. 2. Click the + Add icon on the window. 3. The Add Allergy/ Adverse Effect window opens.

Accessing the Add Allergy Window from the PAL 1. Right click the Allergy Review task.

2. Select Chart Details.

3. Right click in the white area of the Allergies window. 4. Select Add New. 5. Select Drug Allergy. 6. The Add Allergy/ Adverse Effect window opens.

Accessing the Add Allergy/Adverse Effect Window from PowerForms in Ad Hoc Charting 1. Click the box in front of the Allergies. 2. Click Chart or double left click on the Allergies form name.

3. Right click in the white area of the Allergies window. 4. Select Add New. 5. Select Drug Allergy. 6. The Add Allergy/Adverse Effect window opens.

Entering Allergy Information

ALL Allergies and Reactions are ENTERED using the Add/Allergy Effect Window below

1. The Type field should read Allergy. If it does not, click the drop-down arrow and select Allergy.

Yellow indicates required.

2. Common allergies display below. a. If desired list does not display, click Folders icon to display Common Lists. 3. Click in the Substance field. 4. Double click the desired allergy substance. a. If the allergy is not listed, click the binoculars, then select substance and click OK. b. If the patient is unable to state the substance, free text the substance i.e., blood pressure pill. 5. Click Reaction. 6. Common Reactions open below. a. If reaction is not listed, click binoculars, type reaction and click Search. b. Do NOT type in the Reaction field, then press the Enter key. This may result in incorrect or misspelled reactions. c. All typed or free texted Reactions display with a pencil icon. 7. Double click Reaction. 8. Do not enter Severity. MHC does not use this field. 9. Enter Information Source, using the drop down arrow. 10. Do not enter Onset date unless the allergy occurs during this hospitalization. 11. Enter Category, using the drop down arrow. 12. If a comment is needed, click the Comments button and OK. 13. If entering more than one allergy substance, click OK & Add New and repeat steps. 14. Click OK when finished entering allergies.

Common Lists

4 Note: If the patient had an entry of No Known Allergies entered from a previous visit, the system will generate the following warning:

 To add the allergy and cancel NKA, click Yes.

Common Substance, Food, and Environmental Lists

1. Click the Folders icon. 2. Click desired common list.

No Known Allergies The patient is not allergic to any substance. This is the broader general term used for no allergies to medications or any other substance. From the Demographic Bar 1. Double click on the Allergies section of the Demographic Bar. 2. Click No Known Allergies on the Custom Information window. 3. Click OK. 4. Close the window.

Ad Hoc Charting or PAL 1. Access the form. 2. Right click in the white area. 3. Click Add New. 4. Click No Known Allergies.

Note: Once allergies have been entered on a patient, the “NKA” button is dithered (grayed out). To re-enter No Known Allergies the existing allergies must to be canceled first.

No Known Medication Allergies The patient is not allergic to any medications. The patient is allergic to food, environment or other substances. Anytime a patient has a non-medication allergy ALONE, NKMA must be documented also.

When entering and reviewing allergy information, users must indicate No Known Medication Allergies for all patients with environmental or drug allergies (ie. Latex or eggs), but no allergies to medications.

From the Demographic Bar 1. Double click on the Allergies section of the Demographic Bar. 2. Click No Known Medication Allergies on the Custom Information window. 3. Click OK. 4. Close the window.

Enter the patient’s non-drug allergy. Be sure to select the correct category, ‘environment’, ‘food’, or ‘other’.

6 When opening the chart of patients with only non-drug allergies documented or only No Known Medication Allergies without a non-medication allergy entered, users will see one of 2 new alerts alert.

User needs to add “No Known Medication Allergies” (if patient truly has no med allergies).

User needs to add non -medication allergies using the Allergy Search (if patient truly has non- med allergies).

Allergy substance is not available in the search tool The ability to enter free text allergies is available. Use this option with caution. Free text allergies entered in PowerChart are potentially unsafe for patients. The system is set to search for the same or similar products and alert the pharmacist to the allergy. Free text allergies are not recognized by the pharmacy system when orders are being entered. No alert will display for the pharmacist. Entering a free text allergy creates the potential for a patient to receive a drug to which they are allergic.

1. Enter substance, click binoculars.

2. No item displays, click Cancel. Click Free text box.

3. Click OK to alert.

4. Complete process.

7 Unable to obtain allergy information When the patient or other sources (family, old records or family physician) are unable to provide allergy information, enter ‘Unknown” in the Add Allergy Substance field. An Allergy report is printed at 0700 and 1900 daily as a reminder to the unit to obtain allergy information. Communicate the inability to obtain allergies to Pharmacy by written order or phone.

Canceling an allergy Allergies should only be canceled if entered in error or if there is a physician order. From the PAL tab, Ad Hoc Charting, Demographic Bar, or Patient Info tab:

1. Right click on the allergy to be canceled. 2. Click Cancel with drug name

3. Click drop down arrow in Reason field. 4. Click OK.

Modifying an allergy 1. Right click on the allergy to be modified. 2. Click Modify. 3. Add or change the reaction. 4. Click OK.

My Favorites Each user can create “Favorites” for both allergy substances and reactions. Favorites can be created from searching the Substance or Reaction fields using the binoculars. Click in the Substance field: 1. After typing the desired substance, click the binoculars. While the list is displayed, click the desired substance, and the Add to Favorites button. Click in the Reaction field: 1. After typing the desired reaction, click the binoculars. While the list is displayed, click the desired reaction, then click Add to Favorites.

The next time allergies are entered rather than searching, click Favorites and select the substance or reaction from there.

8 Viewing Current Allergies only To view allergies without canceled entries, the display drop-down field should display active. To view cancelled allergies, select all or inactive from the display drop down box.

Allergy Verification Process Verification is the process of reviewing allergies and reactions that have been entered on a previous visit. Allergies can be verified from the Demographic Bar, Floating Menu, or the Allergy form via the PAL or Ad Hoc Charting. 1. Using one of the methods listed above, review allergies and reactions with the patient. 2. Add new allergies or cancel as necessary.  If the patient states they do not have a listed allergy, the physician is to be notified and an order entered to pharmacy for removal. ‘Request for Allergy Removal by Pharmacy,’ via POE VORB/TORB. 3. If all allergies are correct, click Mark All as Reviewed.

4. If reviewing only part of the list:  Right click on each specific allergy.  Select Mark All as Reviewed.

Additional Information for the Allergy Review Process:  Verify NKA in the same manner as any allergy entry.

Tips

 Enter or verify allergies within one hour of admission. The physician/provider and the pharmacist need the information to ensure the patient receives the correct medication in a timely manner.

 Verify the allergies on re-admission by selecting Mark All as Reviewed or right click on the drug and review individually

 Avoid Free Text when entering allergies and reactions. Free-text entries will not cross reference with the ordered medications. The pharmacist will not receive an alert if an ordered drug is listed as a free- text allergy.

 Use the Common Substance, Reaction, Food, and Environmental lists. These tabs are helpful in avoiding free-text of allergies and reactions.

 When searching for a substance or reaction use the binoculars. Avoid typing, then pressing the Enter key which can result in abbreviated or misspelled reactions.

 Latex is listed in the Environmental folder. If the Substance search is used, type “latex”, not “Allergic to Latex”.

 The user does not need to fill in the Onset date or Source fields.

 Allergies must be written on any paper MAR. (printed for downtime, code blue, discharge etc.)

 The user must cancel an allergy that is a clerical error. Select the Reason for cancelation as ‘Error’.

 If the patient informs the user the current PowerChart Allergy list is not accurate, the provider must be notified. An order to cancel allergies must be entered, “Allergy Removal by Pharmacy” before the disputed allergies can be cancelled by Pharmacy. Add a comment when canceling an allergy for this reason.

 To reactivate a canceled allergy: a. Right click the allergy and select Modify. b. Click the drop down arrow in the Status field, and select Active. c. Click OK.

 When allergies have been entered on a patient the “NKA” button is dithered (grayed out). To re-enter No Known Allergies the existing allergies need to be canceled first.

 Add hard to find allergy substances to My Favorites tab to avoid errors.

Incorrect Correct entry Novacain Novocain Statins HMG-CoA Reductase Inhibitors Ace Inhibitor Angiotensin Converting Enzyme Inhibitor ARB Angiotensin II Inhibitors Flu Vaccine Influenza Vaccine Tetanus Vaccine Tetanus Toxoid Contrast Media Iodinated Radiocontrast Media (listed on the Catalog tab) Sulfas Sulfa Drugs (listed on the Catalog tab)