Entering Allergies, Diagnoses, and ICD-10 Codes

Enter an Allergy

1. Click on "Select Resident" under the "Resident" tab.

2. Select a resident.
3. Click on "Allergies" under the "Medical" dropdown tab.
   • This page displays the resident's current allergy information. The resident might also have historical allergy and inactive allergy information if your community has been using BlueStep for a while. If no known drug, food, and environmental allergies have been entered, this page will display No Know Known Allergies. 
   
4. To enter a new drug allergy or food and environmental allergy, click on the "New Entry" button.
5. Fill out the form.
   1. Select the type of allergy.
   2. Enter the allergy name.
   3. Enter an onset date if known.
   4. Choose the severity of the allergy from the dropdown.
   5. Choose the reaction of the allergy from the dropdown.
   6. Enter an end date if applicable. This will inactivate the allergy.
   7. Click the "Staff Signature" button.
   
6. Click the "Save" button to finish.

Enter a Diagnosis

1. Click on "Select Resident" under the "Resident" tab.

2. Select a resident.
3. Click on "Diagnoses" under the "Medical" tab .
   • This page displays the resident's current diagnoses information.
   
4. To enter a new diagnosis, click on the "New Entry" button.
5. Fill out the form.
   1. Select the type of diagnosis.
   2. Enter the diagnosis name. If "ICD-10 Diagnosis" was selected in the previous step, this text field acts as a search field for official ICD-10 codes. If "Other Diagnosis" was selected in the previous step, this is a free text field, meaning anything can be entered.
   3. Enter the start date for the diagnosis.
   4. Enter an end date for the diagnosis if applicable.
   5. Click the "Signature" button.
   
6. Click the "Save" button to finish.

Discontinue a Diagnosis

1. Click on "Select Resident" under the "Resident" tab.

2. Select a resident.
3. Click on "Diagnoses" under the "Medical" dropdown.

4. Select the diagnosis you wish to discontinue.
   1. The "Items Using Diagnosis" section at the bottom of the form shows if the resident is taking any medications specifically for this diagnosis. It is recommended to not discontinue diagnoses if there are active medications for the diagnosis.
   2. Enter an end date for the diagnosis.
   3. Click the "Discontinue Now" button.
   
5. Click the "Save" button to finish.

Rearrange the Resident Record Summary/FaceSheet

The order of information on the resident's Record Summary, also known as the resident's FaceSheet, can be customized. See the Setup: Resident Record Summary/FaceSheet help topic for more information.

How to Make ICD-10 Codes Required

Some pharmacy integrations and policies require ICD-10 codes for diagnoses in place of free-text for diagnoses.

1. Click on "Community Record" under the "Community" tab.

2. Click on "Setup: Medication System" under "Medication" under the "Setup" dropdown.

3. In the "Medication - Prescribed Form" section, select the "On" button in the "Pharmacy Compliance - NCPDP" field. This makes entering an IDC-10 code required when entering a diagnosis.
4. Select the "Make diagnoses required" button in the "Diagnoses" field. This makes entering a diagnosis required when entering a medication.

5. Click the "Save" button to finish.