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Component documentationAllergy Documentation

 

You generally document allergies on a patient-related basis.

The "Allergic to" documentation means you enter the allergen(s).

Further attributes can be optionally entered for each allergen, e.g. allergy type, certainty and rating. There can be one or more different allergic reactions to an allergen. You can specify the degree of severity for each reaction.

Input helps are configured in the project and have customer-specific significance. The input help for allergens consists of a catalog which can be created institution-specifically. The structure and content of the catalog are project-specific. In principle you can structure the catalog in such a way that individual agents can be selected as allergens and also an agent group (precisely this level and not the collected items which lie below!)

In accordance with international standards, allergen groups (for example, food allergies, plant allergies, drug allergies) are considered as a technical classification criterion. The allergen catalog has been defined so that such allergen groups must be defined as the topmost sort criterion. The system evaluates the entries at the topmost level in the allergen catalog as allergen groups and offered or dynamically preset in the allergen selection help accordingly.

Allergy Documentation Info Block

The allergies entered for a patient are displayed in the clinical overview of the documentation work station if the administrator configured the Allergy Documentation info block for display.

You can find information on the Allergy Documentation info block under Allergy Documentation Info Block, and general information on info blocks under Clinical Overview.

Integration

You access the allergy documentation

  • as a function call from the clinical work station. Depending on Customizing you can find the Edit Allergies, Display Allergies function keys and / or a column for the allergy status with a hotspot jump.

  • via a task in the documentation work station. Depending on how task management is customized you might find a task that prompts you to document the patient's allergies.

  • on the SAP Easy Access screen by choosing   Clinical System  Clinical Documentation  Allergies  .

  • by means of a transaction (N2AD1, N2AD2)

Prerequisites

To use the allergy documentation, you need an allergen catalog (catalog type AD Allergies) and various input helps. You enter this data in Customizing for i.s.h.med under   SAP Healthcare - Industry-Specific Component Clinical System  Clinical Documentation  Allergy Documentation  .

Catalogs for an application are grouped to form a basic catalog set. The allergen catalog must be assigned in a basic catalog set of the AD Allergies work area, in order to be available as selection help in the application. You access basic catalog maintenance in customizing via separate nodes: Cross-Application Settings -> Basic Catalogs

To document allergies by means of tasks in the documentation work station, you need to assign a base item of the type Allergy to the task template. You access task template configuration via Customizing for i.s.h.med:   Care Unit Management  Ward Documentation Work Station  Task Management  Create Templates in Template Management: Select Care Unit Work Station  Select Basis Items  Allergies  

The behavior of the base item can be influenced using a BAdI. To create the enhancement implementation, in Customizing for i.s.h.med choose   Cross-Application Settings  BAdIs for Base Items  Allergy Base Item Type  .

You can display the allergy documentation info block in your clinical overview in Customizing for the clinical overview. You access this via:   Care Unit Management  Ward Documentation Work Station  Clinical Overview  .

Features

Allergy Documentation

When you call the allergy documentation you will access an overview which displays all information on the patient’s allergies.

The allergy documentation is designed in such a way that you first enter the allergen and then further attributes. You can enter multiple reactions and degrees of severity for an allergen, there is a detail dialog for this purpose.

You can select the allergen from a catalog or enter a free text independently of the catalog. You may need to enter a free text if you wish to document a rare allergen which is not maintained in the catalog.

Caution Caution

Checking programs that only work with catalog keys cannot check free texts. If you use this kind of checking programs in your hospital, the check for allergies or intolerances may be incomplete.

Procedures that are classified as harmless on account of the incomplete check for allergies or intolerances could nevertheless result in the patient experiencing intolerances and allergic reactions.

  • Use a checking program that can also check free texts.

  • If you use a checking program that cannot process free text, make sure manually that there are no free-text entries for a patient. You can do this by using the allergen search with a free-text entry. The system compares free texts with catalog data and replaces them with appropriate values including catalog keys. To ensure that the Allergen field contains a catalog value, always check whether the indicator for "original catalog entry" is set. This requires that the Orig.Text column be displayed in the Maintain Allergy Documentation for a Patient Overview.

  • If you use a checking program that cannot process free text but still work with free texts in the Allergy module, inform your employees that the check for allergies and intolerances may be incomplete as a result.

End of the caution.

If you select the allergen group first, the system will restrict the selection help for the allergen to the corresponding catalog items.

You can add a corresponding rating for allergens which you consider to be critical or problematic. In the overview Maintain Allergies for Patient this rating will lead to the coloring of the field containing the allergen.

Alternatively, you can choose “No Allergies Known“ to document the absence of allergies. This documents that no allergies are known to you despite querying or checking for this patient. Caution: This does not guarantee that the patient really doesn't have any allergies.

You can also select "Assessment Not Possible". In this case we recommend you enter a reason in the Comment field. Perhaps the patient cannot be asked or tested due to his general state of health.

You can cancel documented allergies row by row. You can hide or show canceled allergies.

Display of Allergy Status in Clinical Work Station and as "Allergy Documentation" Info Block

The documentation status is displayed as a screen icon in the Allergy Status column in the clinical work station and as web dynpro icons in the Allergy Documentation Info Block.

Status

Meaning

Assessment not possible

Medical staff have tried, patient is not responsive, no results received

No known allergies

Medical staff have actively queried or researched. No allergies were determined.

Nothing documented

Input tables are still empty, no-one has dealt with this.

Allergies documented

Message Control for Allergy Documentation

In the IMG activity Maintain Messages the administrator can determine, for the following messages of message class N2AD, whether the system displays a messages and what type: as a success message, information, warning or error message.

  • 004 Allergen does not exist in allergy catalog

  • 012 Allergen group does not match allergen

  • 013 Allergen: Reaction for Severity missing

  • 014 Allergen has already been entered (check your entries)

Constraints

The risk factors already entered in IS-H are not affected by the allergy documentation and are documented separately. Localized, special solutions for risk factor entry, such as for example ”Singapore-Canada-Database Communication via NMPI” continue to function normally.

This allergy documentation is by no means a specialist solution for allergologists, but interdisciplinarily enables medical personnel to make entries concerning the allergies and intolerances of patients, in simple form. No academic differentiation is made between allergies (IgE antibody induced) and intolerances caused in other ways.

If symptoms occur without (suspicion of) an allergen, this is not entered as allergy documentation.

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