In this Quick Reference Guide, users will learn how to properly document Allergy Injections. This guide Also assumes that the user has a basic understanding as to how to access the Intake MG template.
Documenting Allergy Injections
After accessing the Intake MG template:
- Ensure that the Internal Medicine Specialty is selected.
- Select the Nurse Visit option from the Visit Types window.
- Click OK.
Historian
Record the person providing the information in the Historian field. Self indicates the patient is the Historian.
The Addt'l Historian/s field can be used to document additional Historians.
Reason for Visit
To document the Reason for Visit:
- Free text Allergy Injections in the Other field.
- Click Add.
HPI
To document the HPI information:
- Free text Patient given injections from... (See screenshot for details)
- Click Save & Close.
Vital Signs
Record the following information using the Vital Signs template:
- Temperature
- Blood Pressure and pulse
- Click Save
- Click Close
Adding Assessment
To add an Assessment:
- Hover over the Navigation MG bar with your mouse.
- Choose the Assessment option from the menu.
Click the Problem(IT) button.
The Assessment can be selected directly from the Billing Diagnosis History grid, if it was previously recorded. (See Image Below)
In the IMO Problem IT Search window:
- Free text the diagnosis in the Search field.
- Click Search
- Select the diagnosis by clicking the blue button with the plus(+) sign.
In the Diagnosis Status Mstr window:
- Select the Routine option.
- Click OK.
- Click Save & Close.
Ordering and Documenting Injection(s)
To order and document injection(s) information:
- Click the Office Procedures tab.
- Select the desired diagnosis from the Today's Assessments list.
- Click the Allergy drop down arrow.
From the Allergy pop-up window:
- Select the Allergen Immunotherapy 2+ Inject (92117) or the Allergen Immunotherapy, one Injection (95115) option.
- Click OK.
To complete the order:
- Enter the Antigens Expiration Date.
- Click the Performed check box.
- Ensure that the Location and Provider information is green.
- Click Place Order.
- Click Save & Close.
Click Cancel if the Tasks recipients window opens after placing order.
Generate Note
A printable document of today's events must be generated. To generate the document:
- Click the SOAP tab.
- Click the Generate Note icon.
- Select the Master Document option.
- Click OK.
