Summary, allergies and conditions
Where: Care → Beneficiaries → open the person → Health record.
Who: view care.health.view; change care.health.manage.
Coded entries: how to name things
Allergies, conditions and immunisations ask what it is, and optionally a code:
| Field | What to enter | Example |
|---|---|---|
| Name (first field) | The plain name | Penicillin |
| Code system | Free text (no code), ICD-10, ICD-11, SNOMED CT, LOINC, CVX, ATC or Local | Free text (no code) |
| Code | The code in that system; empty for free text | (empty) |
Use free text unless your organisation codes clinical data; no code lists are built in. A coded entry needs a code ("A code is required for …"); free text must not have one ("Free-text entries (TEXT) have no code").
The summary
| Field | What to enter | Example (Ruth) |
|---|---|---|
| Blood group | Unknown, A pos, A neg, B pos, B neg, Ab pos, Ab neg, O pos or O neg | Unknown |
| Allergy status | Unknown (not yet asked), No known (asked: none) or Has allergies | Has allergies |
| Allergies reviewed on | When the allergy status was last checked | 10/01/2026 |
| Dietary requirements | Diet and texture | Soft diet; diabetic |
| History before admission | Relevant history | Hip replacement 2019; lives alone since 2022 |
Select Save summary.
Always ask and record. You can't set No known while active allergies are listed: "There are active allergies; resolve them first".
Allergies
| Field | What to enter | Example |
|---|---|---|
| Substance (coded) | What causes it | Penicillin |
| Category | Food, Medication, Environment or Biologic | Medication |
| Criticality | Low, High or Unable to assess | High |
| Reaction | What happens | Rash and swelling of the face |
Select Add allergy.
What happens:
- a High allergy shows the alert "Severe allergy: Penicillin" at the top of the profile;
- new medication orders are checked against active allergies (see orders).
Allergy status
| Button | Use it when | Example |
|---|---|---|
| Resolved | It no longer applies | A child outgrew an egg allergy |
| Reactivate | A resolved allergy has come back | Reaction recurred |
| In error | It was recorded by mistake. You're asked "Why is this entry wrong? It stays on record, marked in error." | Recorded on the wrong resident |
A real change in the allergy isn't a mistake: use Resolved. Use In error only when it was never true ("Use entered-in-error to correct a mistaken allergy").
Conditions
| Field | What to enter | Example |
|---|---|---|
| Condition (coded) | The diagnosis or problem | Type 2 diabetes |
| Category | Diagnosis, Problem, Disability or Mental health | Diagnosis |
| Clinical status | Active, Recurrence, Remission or Resolved | Active |
| Verification | Unconfirmed, Provisional, Confirmed or Refuted | Confirmed |
| Onset | When it started | 03/2015 |
| Note | Optional | Diet-controlled until 2024 |
Select Add condition. Mental health conditions also appear in Care's Later life section.
When it ends: select Resolved on its row; it's resolved as of today. The clinical status can't be changed in place: if a condition goes into remission or recurs, record that as a new entry with the new clinical status (and resolve the old one if appropriate).
Examples:
| Situation | What to record |
|---|---|
| GP diagnoses high blood pressure | Hypertension · Diagnosis · Active · Confirmed |
| Suspected, waiting for tests | Clinical status Active · Verification Provisional |
| Tests show it isn't so | Verification Refuted (don't delete it) |
| Wrong resident | In error with the reason |
Correct any mistake
- On the entry, select In error.
- Give a clear reason, for example "Recorded on the wrong resident".
- Add the correct entry if needed.
- Tick Show entries marked in error to see the original.
Nothing is deleted, so the record shows exactly what was known, and when.