Documenting Shots - health.state.mn.us

1 Documenting Shots It would be much easier if we all did it the same way! This section is filled with tips and tools to make Documenting Shots a more Remember: accurate, less complicated task. "If it isn't Overview of this section: documented, it isn't Best Practices Checklist: Documenting Shots done!". Why Document Shots How to Document Shots Where to Document Shots Documenting for Child Care and School Key Resources for Documenting Shots Who to Call MIIC Help Desk 651-201-5503. 800-657-3970. Minnesota immunization Program For Minnesota specific issues ( Minnesota school law). 800-657-3970. 651-201-5503. July 2011, Minnesota Department of Health Got Your Shots ?

2 Providers Guide - Documenting Shots 181. Best Practices Checklist: Documenting Shots The information in this checklist will be covered in more detail throughout this section. How to document Shots We train our staff on what immunization documentation is essential and required by law. We keep accurate, readable, up-to-date immunization records. We participate in the Minnesota immunization Information Connection (MIIC) to ensure vaccination records are available. Where to document Shots We always update the patient's personal immunization record with information on the vaccines we administer. We update the patient immunization record with vaccines received at other clinics, when we have appropriate documentation.

3 We make sure patients don't leave without a personal immunization record that contains their immunization history. If we don't give a vaccine when it's due, we document the reason why in the patient's chart. Documenting for child dare and school We train staff on documentation required for child care and school under Minnesota's immunization law. 182 Got Your Shots ? Providers Guide - Documenting Shots Minnesota Department of Health, July 2011. Why records are important Why Written or electronic documentation is the only way to make sure your patient: Document yy Receives the Shots he or she needs at the recommended age and intervals.

4 Shots yy Isn't over-vaccinated which is not only costly but painful. yy Has the Shots needed for child care and school, or for a job or international travel. What immunization information is needed or required? How to Every time you give an immunization , certain information must be documented in Document the patient's immunization record either because it is required by federal law or it is necessary to document administration of a prescribed drug ( , vaccines). Shots See the table Documenting Vaccine Information on pages 184-185. Additional documentation may be required by state regulation or your facility. Be sure your facility has a written policy that describes what documentation is necessary and where it should be documented.

5 Required by federal law Federal law requires you to document the following information as part of the National Childhood Vaccine Injury Act when you administer recommended vaccines to children as well as adults; see immunization Laws on page 203. yy Date vaccine given yy Date of publication of the Vaccine Information Statement (VIS) (see Instructions for the Use of Vaccine Information Statements on page 143.). yy Date the VIS was given to the patient (or parent/legal guardian). yy Manufacturer and lot number of vaccine yy Name, title, and clinic address (location where immunization information will be stored) of the individual who administered the vaccine Essential to document As a best practice for Documenting immunizations, the following additional information is essential to document: yy Vaccine type yy Route and site of administration yy Dosage yy History of a vaccine reaction yy Contraindications yy Patient's date of birth July 2011, Minnesota Department of Health Got Your Shots ?

6 Providers Guide - Documenting Shots 183. How to Document Shots Documenting Vaccine Information How to record .. Guideline Example(s). Required by federal law Date vaccine given Use MM/DD/YYYY. 06/24/2010. Document the month, day, and year found on Date on VIS 08/10/2010. the VIS itself; use MM/DD/YYYY. Document the month, day, and year the VIS. Date VIS given to was given to the parent (or vaccinee); use 10/10/2010. patient MM/DD/YYYY. MSD for Merck & Co, Inc. Vaccine Use 3-character abbreviation; these codes are See Vaccine Manufacturers for manufacturer universal and the same codes used by MIIC. Selected Childhood and Adult Vaccines on page 201.

7 Indicate the lot number as printed on the vial, syringe, or box. For combination vaccines use 470-527. Vaccine lot number the lot number on the box; it is linked to the 5160C9. vaccine diluent and powder. Document name and title of person Person Mary Jones, RN. administering vaccine. administering vaccine Document the address of the clinic where the Main St. Clinic, 1111 Main St., City, vaccine was administered. MN 55555. Essential to record Hib, HepB, DTaP. Use standardized vaccine abbreviations. (See table on page 199.). Use numbers or additional letters, if Hib(PRP-T), Hib(PRP-OMP), HPV2, necessary, to distinguish different vaccines for Vaccine type HPV4.

8 The same disease. Note: Indicating the type of vaccine is important when you give DT-pediatric rather than DTaP since children who receive DT-pediatric will be at higher risk of pertussis disease if there is a pertussis outbreak in the community. Continued 184 Got Your Shots ? Providers Guide - Documenting Shots Minnesota Department of Health, July 2011. How to Document Shots Essential to record, continued yy Pentacel is DTaP-IPV-Hib. Record it under DTaP, IPV, and Hib. yy Twinrix is hepA-hepB. Record Document a combination vaccine under each Combination it under both hepatitis A and specific antigen the vaccine contains; use a vaccines hepatitis B.

9 Hyphen between each antigen. yy Pediarix is DTaP-IPV-hep B. Record it under DTaP, IPV, and hepatitis B. Route of Intramuscular (IM), subcutaneous administering Document method of administration. (SQ or SC), oral (PO), intranasal vaccine (ITN). Site of Right thigh (RT), left thigh (LT), right administering Document location of administration. arm (RA), left arm (LA). vaccine Dosage Document the vaccine dosage. mL, If a patient experiences a clinically significant or unexpected event after an History of vaccine immunization (even if you are uncertain the vaccine caused it), provide specifics about reaction the event in the patient's chart.

10 See Report adverse reactions to vaccines on page 160. Indicate any vaccine contraindications the patient has; provide specifics in the Contraindications patient's chart. See Contraindications and Precautions to Commonly Used Vaccines on page 135-138. Patient's date of Use MM/DD/YYYY. 04/24/2010. birth July 2011, Minnesota Department of Health Got Your Shots ? Providers Guide - Documenting Shots 185. Where to Documenting immunizations in the patient's medical record Document Whether you document immunizations on paper or electronically, make sure to Shots include all of the required and essential information. See What immunization information is needed or required?