Medical History:
Immunizations Medical History:
Immunizations
The following topics are discussed on this page. Use the links to jump to the desired subject:
Introduction to the Immunization History
To generate the CCD (Continuity of Care Document)
The Immunization History page allows you to capture and maintain a list of all immunizations/immunity a patient has had over time. A chronological change log is also available, which records the original content, change reason, and an audit trail of the user ID and date/time stamp.
To access the Immunization history page, use one of the following methods:
(Preferred method) From the Hospital Main page, use the Select button to select the appropriate patient using the drop-down list. Then, click the Immunizations button. The Medical History: Immunization page is displayed.
OR
Click the Immunizations button on the Hospital Main page. The Patient Search box is displayed. Begin typing the patient information. See Selecting Patients for additional details on using this feature.
Once the patient is selected, the patient's basic episode information is displayed in the yellow bar at the top of the screen, including: patient name, DOB, and medical record number.
The Immunizations page has two sections: Immunizations and Immunity. All immunizations display the description, manufacturer, lot number, expiration date, administered date, frequency, next due date, and verified by information. In addition, the following function buttons are displayed for each immunization on the list:
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Edit button: Click to edit an immunization. See To edit an immunization. |
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Remove button: Click to remove a surgery from the surgery list. See To remove an immunization. |
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View Change Log button: Click to view all details of any changes. See To view the Change Log. To return to the Immunization List, click Back. |
Click Add Immunization located at the top of the page. The Add Immunization box is displayed.
In the Immunization field, use the drop-down list to select the desired immunization.
In the Dosage field, enter the Dosage amount for the immunization.
In the Route field, use the drop-down list to select the appropriate route that the patient received the immunization.
In the Site field, use the drop-down list to select the body location that the patient received the immunization.
In the Manufacturer field, type the name of the manufacturer of the immunization.
In the Lot No field, type the lot number for the immunization.
In the Expiration Date field, use the drop-down list to select Day, Month, or Year. In the blank date field to the right, click the calendar to select the date the immunization expires. The date is automatically formatted according to the selected day, month, or year.
In the Administration Date field, use the drop-down list to select Day, Month, or Year. In the blank date field to the right, click the calendar to select the date the patient had the immunization administered. The date is automatically formatted according to the selected day, month, or year.
(Optional) In the VIS Presented Date field (Vaccine Information Statement), the date on which the patient or family member was provided information/material regarding the immunization.
In the Vaccines for Children field, use the drop-down list to select if the patient is eligible for the Vaccines for Children program.
In the Immunization Registry Status field, enter the status of the Immunization Registry.
In the Immunization Registry Status Effective Date field, enter the date that the status identified in the previous step became effective.
(Optional) In the Immunization Information Source field, select the of the information regarding the immunization.
In the Send Reminder field, select the appropriate type of reminders to generate for this immunization item, if desired.
In the Reminder Effective Date field, enter the date that the reminder identified in the previous step became effective.
In the Next Due Date field, use the calendar to select the date when the immunization is due again.
The Consent to Share Immunization Information check box is used to grant permission to submit this immunization data to the registry.
In the Consent Information section, complete the Date, Decision, Decision By (enter the name of the individual who gave consent for the immunization information to be shared), and Relationship to Patient fields.
In the Comment field, you can type a free-text message about the immunization.
Click Save and Add More to add the immunization and remain in the window to add additional immunizations.
Or, click Save and Close to save your work and return to the list.
The No Change option allows you to indicate that you have reviewed and verified that the immunization list is correct and hasn't changed since the last assessment/review.
Click No Change located at the upper right-hand corner of the window.
A message box is displayed with the message, Would you like to mark all immunizations as being reviewed and verified? Select Yes to indicate you have reviewed and verified the immunization list, and click Save; or select No or click Close if you do not want to perform the verification at this time. Once reviewed, the user name and date/time is displayed in the Verified column.
Click 
next
to the immunization you want to edit. The Edit Immunization box is
displayed. Edit any of the fields as needed. See above for field descriptions.
In the Reason field, use the drop-down list to select a reason for the edit. To enter a reason that is not listed, select Other (See notes) from the list and type in the required free-text reason in the Other Reason field.
Click Save to save your changes and return to the immunization list, or click Close if you want to cancel your changes.
Click 
next
to the surgery you want to remove. The Remove Immunization box is
displayed.
In the Reason field, use the drop-down list to select a reason for removing the item. To enter a reason that is not listed, select Other (See notes) from the drop-down list and type the required free-text reason in the Other Reason field.
Click Remove to continue. You are returned to the list with the item now removed.
A change log is available to view all details of a change made to the items. The log records when an item is added, edited, or removed, and contains the login name of who made the change, a reason for the change, and both the original and new values of the description, date, and notes.
There are two ways to access the change log:
Click View Change Log at the top of the screen to view changes for all items on the list.
Click the 
button next to an individual
item to view changes for only that item.
On the Immunization Change Log page, immunizations are displayed according to the date/time they were changed, with the most recent change first. You can alter your view to display only added, edited, or removed items, as well as, sort the items by description. To change your view, use the drop-down lists in the Filter and Sort fields to select your desired view options. Once selected, the list is resorted accordingly.
The Show All Details option displays additional information for each of the items, including the original and new values, if available.
Click Back to leave the change log and return to the immunization list.
Sometimes a patient becomes immune to an illness because the patient has already had the condition, i.e. hepatitis, chicken pox, measles. When this situation occurs, we need to document that the patient has an immunity to a condition/illness.
The CCD is a clinical summary document generated from the patient's clinical information, including insurance providers, advance directive information, problem list, and medication information. This document opens in a new browser tab, where it can be e-mailed, saved, and/or printed to the patient and/or another healthcare provider. To generate the CCD, click Generate CCD.
To print a copy of the list, click the Print button.
Using the Shortcut Tabs: Search, Demographics, Summary, and Allergy |
Medical History: Allergy List |