Allergies should be reviewed and updated in the electronic record upon admission or during outpatient visits as per the program standards. Allergies are saved to the patient’s medical record. Allergies documented on past admissions will display on the current admission/visit. Refer to NE LHIN Allergies Policy.

Allergies are verified and entered on the Summary Page from the EMR Panel.

• Open the patient’s chart
• Select the Summary tab in the EMR
• Find the Allergy/AdvReac Tab
• Click the blue EDIT button to open the routine
• Click New to enter new allergies OR EDIT to update existing allergies
• Include all possible allergens, not just medication allergies

Confirm Existing Allergies

• The user is responsible for reviewing allergies in the electronic health record for all visits. Following the review, the user acknowledges that the allergies have been reviewed and they are correct.
• Access the allergy section on the summary page of the electronic medical record.
• Open the patient’s chart and select the ‘Summary’ tab in the EMR.
• Find the ‘Allergy/AdvReac’ tab and click the blue ‘Edit’ button to open the allergy routine.
• Review and confirm allergies with the patient.
• Click on each allergy using the checkmark to the left. Details of the allergy will populate the box below.
• Once reviewed, click ‘Confirm’ at the bottom of the page. This will update the date verified to today’s date.

Entering New Allergies

• Click the ‘New’ button at the top of the page. A summary of existing allergies will display.

• Choose the default ‘Starts with’ as preferred search for .

• For medications, enter the name of a medication allergen in the ‘Search for’ field.

• For Food and Environmental allergens, always prefix search with “FOOD-” and “ENV-”.
• Do NOT use foods and environmental allergens that are findable in lookup that don’t start with these prefixes.
• If unable to find desired allergen, then choose “FOOD-OTHER” or “ENV-OTHER” and begin reaction description with name of the specific allergen

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• The selected allergen will be added to the list of current allergies.
• Click on the red EDIT button and respond to the prompts.
• Add the ‘Allergy’ or ‘Adverse Reaction’ and include the reaction for every new allergy entered.
• A dropdown menu of common reactions is available, however free text can be used if the reaction is not available in the dropdown menu (to enter free text option click anywhere on the green highlighted allergen besides the red Edit button).
• More detailed Comment box may be used to enter more lengthy detailed information ●          Pharmacists and physicians may update the ‘type’ and ‘severity’ of the allergies.
• Click ‘Save’. The allergies file on the summary page in alphabetical order.
• Clicking on the plus (+) sign will open a detail box per allergy.
• When allergies are entered, the allergy status defaults to a ‘verified’ status.
• When allergies have been entered or updated, the pharmacist receives an alert when accessing the patient profile. The pharmacist may acknowledge or bypass the allergy alert until the next time the patient profile is reviewed

Entering NKA - No Known Allergies

●    If the patient has no known allergies, click the ‘NKA’ button. Do not select ‘No Known Allergies’ or other similar options from the allergies search list.

Entering Unobtainable Allergies

Click the ‘Unobtainable’ button if the patient is unresponsive or otherwise unable to communicate their allergies.

Entering Uncoded Allergies (Allergies not found in the Allergen Lookup)

• Entering an allergen that is not found in the allergen lookup will generate a warning that there are no matches in the system and you are prompted to add as ‘Uncoded’.
• Click on the Add as Uncoded button to add this allergen to the list as a LAST RESORT if you can not find an appropriate medication allergen in lookup. Not that Uncoded is NEVER required for Food or Environmental allergens since these are to be entered under the “FOOD-OTHER” AND “ENV-OTHER” options.
• The allergen will not be automatically cross checked with medications because it does not exist in the allergen dictionary.
• The allergen is not marked as ‘Verified’ but rather as ‘Uncoded’.

Removing an Allergy

• Allergies may be removed by Nurses, Pharmacists, Physicians, Midwives, Physician Assistants, Nurse Practitioners and Dietitians with appropriate documentation of reasoning within the allergy routine.
• An in-depth assessment must be conducted prior to removal of an allergy. It is important to ensure that the previously documented allergy was not a serious reaction that the patient may have been unaware of (example heparin-induced thrombocytopenia).
• If appropriate, allergies may be removed with clear rationale for doing so within the allergy section of Meditech Expanse.

Revision History