In this section, you will review the steps needed to document vaccines administered to a patient that were not ordered.
- Click on the Chart button on the toolbar or press F8 on your keyboard to open the patient's chart.
- Click on the Immunizations tab. This will open the patient's immunization Forecast Window.
Patient Chart: Immunization Tab
- Click on the Enter Immunization button and the Immunization Order Management Window opens.
Immunization Management Window
|Note: Vaccines are grouped by antigen category. The tabs along the middle list groupings such D-T-P, Polio, HIB, Flu, Infant, Teen/Adult, etc. The top section of the window shows the vaccines. The bottom section shows the vaccine record for this specific patient.|
- Select the tab by clicking on it. This will show you all the vaccines in that section.
- In the example above, I want to document that I gave the ActHib (HIB-PRP-T) vaccine. This vaccine is located under the 'HIB' tab.
|Note: Antigen is listed in the box and underneath is the brand name.|
- Click on the box listing the antigen name. Tis will open the 'Vaccine Administration Information" window.
- When I click on the "HIB-PRP-T" vaccine, the "Enter Vaccine Administration Information" window opens.
Enter Vaccine Administration Information Window
- Confirm the vaccine information: manufacturer, expiration date, and lot number.
- Choose Body Site from the dropdown.
- Check over the information on the window.
- Click Save when complete.