# Documentation of Vaccines/Injections???



## SScoder

I have discovered that the Nurse/Med Tech are NOT documenting when they give a Vaccine or injection.  The Physician is dictating that the vac./inj was given; but does not mention that the Nurse/Med Tech gave the inj etc.  

" Pneumovac was given" is the documentation. ???????
Am I crazy to be concerned over this?   Shouldn't they be documenting type, dosage, route etc and initialing those?

I have discussed my concerns with Dr's and Office manager, but I can not find WRITTEN documentation to support my concerns.  Any information to support or dispute my concerns will be greatly appreciated.  Thank you , su


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## Kris Cuddy

Su,

Your concern is shared. Documenting any injection, or vaccination, is very important.

There are multiple ways injections and/or vaccinations may be given, including but not limited to; intramuscular (IM), subcutaneous (SQ), etc.

Also, there are multiple manufacturers and brands of vaccinations. There are multiple ways vaccination may be purchased, e.g., single dose vial, single dose injection, multiple dose vial, etc. For each of these differences, there is a unique National Drug Code (NDC) number. In addition, there is a lot number on each vial or single dose injection (with needle attached).

CDC has some standards I believe will help support your request for more appropriate documentation. The website address is:
http://www.cdc.gov/vaccines/recs/vac-admin/rev-immz-stds.htm

It is recommended that whoever is performing the vaccination document the vaccination given, the route given(IM, SQ, etc.), and the lot number, as well as their complete signature along with credentials. Initials are ok if ancillary staff are documenting on a flow sheet, but for an actual chart note the legible identity and credentials are to be written.


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## MsMaddy

I agree, in our office we give all kind of vaccination and flul vac, we have 
all nurses and doctor's who perform this must document in chart or I will go to them and have them chart it or other wise if not documented I will not coded.  Keep in mind anything that is done to the patient, must be documented even if the pt leaves a message or if you call the pt and leave them a message has to be documented. 

Hope this helped!

MsMaddy


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## bhaskins1

WOW what a scary thought... your vaccine record follows you throughout your entire life.  I work for a pediatrician's office and we still on occasion have adults come to our office to retrieve their vaccine records because they have to prove to work or school that they have had specific vaccines.

Also what happens if there is a recall on a specific vaccine and you can't tell the patient (or parent in our case) that their child did or did not get that specific brand or lot number?  

I'm in NC and our state Mandates careful record keeping.  Every vaccine we give is documented on the patient's vaccine record with lot number, brand, location of shot, and signature... also the initials of the parent or guardian who authorized the shot. 

Just some things to think about.


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## Kris Cuddy

Good notation, Barbara of the flow of injection/Vaccination documentation. I forgot to note the location in my prior post. The location on the patient's body where an injection is given, e.g., L deltoid, etc.


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## SScoder

Thank you for validating my concerns.. I will continue to 
educate Dr's and Office manager on this matter


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## SScoder

kforkismet said:


> Su,
> 
> Your concern is shared. Documenting any injection, or vaccination, is very important.
> 
> There are multiple ways injections and/or vaccinations may be given, including but not limited to; intramuscular (IM), subcutaneous (SQ), etc.
> 
> Also, there are multiple manufacturers and brands of vaccinations. There are multiple ways vaccination may be purchased, e.g., single dose vial, single dose injection, multiple dose vial, etc. For each of these differences, there is a unique National Drug Code (NDC) number. In addition, there is a lot number on each vial or single dose injection (with needle attached).
> 
> CDC has some standards I believe will help support your request for more appropriate documentation. The website address is:
> http://www.cdc.gov/vaccines/recs/vac-admin/rev-immz-stds.htm
> 
> It is recommended that whoever is performing the vaccination document the vaccination given, the route given(IM, SQ, etc.), and the lot number, as well as their complete signature along with credentials. Initials are ok if ancillary staff are documenting on a flow sheet, but for an actual chart note the legible identity and credentials are to be written.


Thank you!!  see also the FEDERAL REGISTER  online at 
"http://wais.acess.gpo.gov [DOCID:FR28au08-74]  or August 28, 2008 ( Volume 73, Number 168) [Page 50821 - 50824].  Note that page 50822 gives specific documention instructions.


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