Entering Medication, Allergies and Medical History information

Information about a patient's past medical history - including medications, allergies and conditions - can be entered on the patient history (Pt. Hx.) tab. 

Medications

Medication information can be entered in a few different ways.

Your practice administrators have the option of setting up a list of common medications patients report in their medical histories. If a patient reports they are taking a medication on the common list, simply click on the name of the medication in the list. The common medication list can be found on the right side of the medications section. When you click on the medication name, you will be asked to enter sig information, as well as a start and end date. This information is optional. After you have added any of the optional information, click on the "select drug" button. If you accidentally selected the wrong drug, simply click the "cancel" button.

If a medication is not on the common list, enter the name of the medication in the search box at the top of the Medications section and click "search." You will be presented with a list of medications that match what you searched for. Click on the appropriate medication, and from here the steps are the same as if you had clicked on a common medication.

The third way to enter a medication is as free text. You can use this option if the patient reports taking a medication not on the common list. (Please note that Stratus EMR utilizes a comprehensive drug database, and oftentimes a medication won't show up in a search due to a spelling issue.) To use the free text option, click on the "enter free text" button at the top of the Medications section, enter the medication, start date and end date, then click on the "enter" button.

If you are utilizing the e-prescribing module of Stratus EMR, you also may have access to the patient's medication history as reported by a pharmacy benefit manager. If such information has been reported, the words "reconcile meds" will appear at the top of the Medications section. Click on this to open a list of the medications reported by the  pharmacy benefit manager. You can then select to either import a medication or delete it.

Allergies

Entering allergy information is similar to entering patient medication history.

To select an allergy from the common list, click on the name of the allergy. This will open up a box that asks for the reaction type. Select that and then click the "enter" button.

If an allergy is not on the list, you can search for it using the search box at the top of the Allergies section. When the search results are returned, select a reaction type from the dropdown menu at the top of the search results and then click on the name of the drug you'd like to select. The allergy search feature queries the same database as the medication search feature, though the allergy search also returns drug classes.

You also have the option of entering an allergy as free text. You can do this in the same way you enter a free text medication

Medical History

As with the other patient history items, you can enter medical history from a common list, from search results or as free text. 

To enter from the common list, simply click on the condition name, enter the start date and end date (this is optional), then click the "enter" button.

If a medication is not on the common list, you can search for it using the search box. When the search results are returned, enter the start date and end date (this is optional), then click on the condition to enter it into the patient's record. 

You also have the option to enter the condition as free text by clicking on the "enter free text" button.

 

You can delete an entry from any section by clicking on the trash can icon next to the item. The Medications and Medical History sections also give the option of changing the start or end date values by clicking on the pencil icon next to the item.

Please note that items entered into the patient history as free text cannot be used as part of the drug-drug interaction, drug-condition interaction or allergy alerts in the e-prescribing module. To trigger an alert, the information must be entered from the search results or as a coded value in the common list.  

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