In this video I will describe how to accurately document vaccines after administration.
Best practice includes recording immunizations in both the medical record and
an immunization information system, if appropriate. In addition, give the parent,
patient, or guardian a record of the vaccine administered. Accurate documentation is
necessary to properly assess for needed vaccines and can help prevent administration errors.
It is important that immunization providers know the federal requirements for
documentation. The requirements are defined in the National Childhood Vaccine Injury Act.
This applies to all rountinely recommended childhood vaccines. Despite the name of
the act, the documentation requirements also apply when documenting vaccines given to
adults. The following information must be documented in the patient's paper or
electronic medical record or in a permanent office log: the date the vaccine is administered,
the vaccine manufacturer and the lot number of the vaccine, the date the Vaccine Information
Statement or VIS was provided to the parent, patient or guardian, the VIS edition date
located in the lower right corner on the back of the VIS, the name and title of the person
who administered the vaccine and the address of the facility where the permanent record will
reside. Best practice guidelines for documentation also include the vaccine's expiration date,
the route and site of administration, and the dosage or volume. In addition, vaccines
should be recorded in an immunization information system, if appropriate. Your state or
facility may require additional documentation. The National Childhood Vaccine Injury Act
requires that a VIS must be given to a parent, patient or guardian before administering
vaccine. A VIS must be provided prior to every dose of vaccine, not just the first dose. The
vaccine MMRV or ProQuad, is the only combination vaccine with its own VIS.The other
combination vaccines do not have their own VIS. For example, Pediarix is a combination
vaccine containing DTaP, polio and hepatitis B vaccines. There is not a VIS for Pediarix.
Instead, the vaccine information statements for DTaP, polio, and hepatitis B should be given
and documented. A list of standardized vaccine abbreviations is available on
the Advisory Committee on Immunization Practices webpage. These abbreviations provide a
uniform approach to vaccine documentation and can help prevent confusion. Federal law
does not require a parent, patient, or guardian to sign a consent form in order to receive
a vaccine. Providing them with the appropriate Vaccine Inform- ation Statements and an
opportunity to ask and answer their questions is sufficient. It is also important to
document when recommended vaccines are refused. The American Academy of Pediatrics
has a form available on their website that can be used to document when parents refuse
vaccines. This video is part of a series demonstrating vaccine adminnistration skills and best
practices. The video is available on the Vaccine Admin- istration webpage on the CDC
Vaccines and Immunizations website at www.cdc.gov/vaccines