ProvClinicals

1. ProvClinicals Horizon Expert Documentation Module 2: Allergies

2. This is the second of five modules in this course on Horizon Expert Documentation. This module will focus on the documentation and reviewing of patient allergies.  It is intended for clinicians that chart patients allergy's and/or need access to review allergies to see what has been charted.   By the end of this allergy module you will be able to: Review patients allergies Confirm allergies Add allergies Modify allergies Inactivate allergies 2

3. ProvClinicals has a 3-way allergy system.  When a licensed practitioner enters an allergy in either Provclinicals, STAR, or Horizon Meds Manager (HMM), the allergy is viewable in each of the other systems. Allergies are longitudinal data which means that the information stays from one visit to another visit.  When an allergy is listed in one of the above systems, it will always be available in a patient’s Health History.  3

4. A patient’s allergies are noted in the top right corner of the Care Organizer screen. Each color reflects a different allergy status: Red: indicates that the patient has an allergy Gray: indicates that the patient has no known allergies Yellow: indicates that the patient has no charted allergy information 4

5. If a patient has previously been admitted into a Providence hospital in Western Washington, they will have a Health History documented, and the information from the previous Health History will carry forward to this current admission.  Allergy information needs to be reviewed with the patient to make sure everything documented is still current and accurate.  If changes are needed, this is the time to make those changes.  If the allergy information documented is correct and no changes are needed, then each allergy needs to be confirmed. 5 Allergies need to be confirmed within two hours of admission. Click here for a demonstration.

6. When adding an allergy, there are two different ways to locate the name of the allergy so it can be documented. Click on each link below to see a demonstration for both ways. Selecting an allergy from the dropdown list. Looking up an allergy in the database. 6

7. You have the ability to modify an allergy.  A few reasons why you might need to modify an allergy is that the patient's reaction or severity of reaction have changed,  or you might just need to add a comment. Click here to see a demonstration of an allergy being modified. 7

8. You also have the ability to inactivate an allergy.  You would typically only need to inactivate an allergy if one was entered on the wrong patient or if the allergy was documented in error. Click here to see a demonstration of an allergy being inactivated. 8

9. This concludes the module on Allergies.  You can now continue with the HED course by closing this module and clicking on the next module. Thank you! 9