Overview of Scenario

The EHR or other clinical software system enables capture of structured data regarding adverse events.

Example of Scenario

Dr. Smith examines Juana Maria Gonzales Morales 24 hours after she receives a live, attenuated influenza vaccine. She had fever and diarrhea and, therefore, Dr. Smith entered her observations indicating a possible adverse event.  The EHR stored the observations associated with the specific influenza vaccine.

Guidance

All products reviewed allow entry of allergy and adverse reactions in the allergy list and/or on the patient’s problem list. Some allowed providers to specify the type of reaction (e.g., type of allergy or adverse reaction) and its severity.

• Vendor Perspectives. Vendors should consider usability evaluation such as User Centered Design (UCD) to evaluate how the system documents and stores adverse event data.
• Provider and Implementer Perspectives. Discuss preferences for documenting adverse events with the software vendor.

Tests

Click here for test script scenarios that include the capability, Identify Adverse Event. The scripts also indicate successful performance for each of the test sections.

Data Elements

The data elements include the adverse reaction specific to the clinical scenario in the test script.