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How can I document a medication side effect as opposed to an allergic reaction?

For documenting side effects to medications, we would not recommend adding them to Allergies at all. This area of the EMR is specifically used for Drug-to-Allergy interaction checks against other patient medications as per ONC/CMS Certification requirements.

 

We can suggest these other options:

 

If you are stopping a medication due to a side effect, then this can be noted in the Stop reason list:

 

 

 

However, if you have never prescribed this medication, but the patient is telling you they do not want it due to having had side effects in the past, then you might want to add that medication as Prescribed Elsewhere in the Medical History -> Medications list first. Then you can change the Status to “Do Not Refill” and note that reason:

 

 

This would end up having the medication look like this in the chart:

 

 

Additionally, you can add a Note to the medication using the Notes button. The icon will change to indicate that a note is present on the medication.

 

 

 

Thank you,

 

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  • 27-Feb-2023
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