Documentation of NKDA

nursejeff wrote on Tuesday, May 22, 2012:

I want to mention something I discovered today that I feel is important. 

The majority of patients have no allergies, therefore we click on the “none” selection in the “Allergies” issues.  When printing the patient chart note for that encounter, however, there is no mention in the printed document of  “no allergies.”

If I go into the chart and and add an allergy - such as “no allergies” or “NKDA” then it will show up as a medical problem but clicking “None” does nothing to show that we checked for allergies.

I hope this make sense and get my point across.

Thank you.

Jeff Guillory
NP Health Clinic

bradymiller wrote on Tuesday, May 22, 2012:

Hi Jeff,
Makes sense and agreed. Sounds like need to offer a none selection for the Medical Problems,Allergies,Medications for these when none has been explicitly checked.
-brady
OpenEMR