Regional Immunization Manual

Competency # 10. Documentation

 Competency: Documents information relevant to each immunization encounter in accordance with national guidelines for immunization practices and jurisdictional health information processes.

  • The health professional will be able to perform the following:
  • Describe the role and importance of immunization records.
  • Identify the information to be documented on an immunization record.
  • Record an immunization encounter on the appropriate documentation instruments accurately and completely.
  • Facilitate the transfer of information in the vaccination record to other providers and to appropriate agencies in accordance with requirements.
  • Record the reason and planned follow-up action when a scheduled immunization is not given.

Introduction

The Canadian Immunization Guide outlines the following as the standard for immunization documentation

 Vaccines administered to an individual should be recorded in three locations:

  • the personal immunization record held by the person or his or her parent/guardian;
  • the record maintained by the health care provider who gave the immunization; and
  • the local or provincial registry.

Each method of recording should include the following:

  • trade name of the product
  • disease(s) against which it protects
  • date given (day, month and year)
  • dose
  • site and route of administration
  • manufacturer
  • lot number
  • name and title of person administering the vaccine

ii. Clinical Practice Guidelines

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