Allergies, Adverse Reactions, Warnings

Record a patient's allergies and adverse reactions.

Before you begin

Procedure

  1. Select the Allergies/Adverse Reactions/Warnings tab within the Patient Details window or press F7. Alternatively in the Clinical Window, select Clinical > Allergies/Warnings
  2. Click Add.
  3. In the Add Allergy / Adverse Reaction window, add the source of the allergy:
    • Enter Allergy by Class
    • Enter Allergy by Other: Allows you to free-type an allergy not necessarily related to a particular drug or class. You can also use this option to be more specific. For example if you wanted to record an allergy to EXELON you would normally use the 'By Drug' option and simply look for EXELON. However, if the patient was allergic to only the patch variety of EXELON, you could use the 'Other' option instead, and enter 'EXELON Patch'.
    Items of Interest on this window
    No Known Allergies / Adverse Reactions By ticking this check box you will remove and delete all currently-recorded known allergies and/or drug reactions for this patient. This happens immediately upon ticking the check box, and is not reversible.
    Warnings Section Add free-text warnings to this section. Warnings added will be visible at the top-left of the patient's Clinical Window.
    Drug dependent Ticking this check box will;

    Insert an entry into the 'Actions' header of the current Progress Note.

    Display "Drug Dependent" on the Warning section in the patient's record.
    Elite Sportsperson This provides warnings when prescribing drugs that are banned in sport.
    Breast Feeding The Breast Feeding check box only appears for female patients within the configured age group.
    Update Address for All Family Members Update the address details for other family members, with the details of the current patient. Clinical uses the Head of Family. setting to determine which patients are members of the same family. This option is only available when editing Patient Details from the Clinical Window.
    Auto-Capitalise Names Tick the Auto-Capitalise Names check box to automatically capitalise the first letter of each word you type. There are numerous windows throughout MedicalDirector Clinical that offer this functionality, including the various Options tabs.
  4. Describe the nature of the reaction.
  5. Indicate the Type of reaction.
  6. Indicate the Severity of the reaction.
  7. Click OK to confirm your input.

Results

Allergies added will be visible at the top-left of the patient's Clinical Window.

What to do next

To view a percentage of patients who have not been asked about their allergy/adverse reaction status, see Patient's with Non-Entered Clinical Data. You can also print a list of patients from this search utility.