Enter a Documented Immunity

Version 14.19


Below are the steps to documenting a vaccine immunity.  Note that, from a medical perspective, immunity should not and cannot be documented for some vaccine-preventable diseases.

  1. From the Clinical, Practice Management or Billing tab, navigate to the Patient Chart.
  2. Search for a Patient.  
  3. Click the Problem List button. 
  4. Click the New button.
  5. Complete the following fields:
  • Subsection: Click the Drop-Down Menu and select Documented Immunity.
  • Status: The status defaults to Active, select a Status using the definitions below.
    • Immunity by Documented Immunity: Serology (finding)
      • Active: Current immunity due to new lab results.
      • Tracking: Current immunity due to lab results.
      • Resolved: N/A for immunity by serology.
    • Immunity by Documented Immunity: Disease (disorder)
      • Active: Current immunity due to active disease/disorder.
      • Tracking: Current immunity due to recent disease/disorder.
      • Resolved: Current immunity due to positive history of disease/disorder.
  • Onset Date: Click the Drop-Down Menu and select from the Calendar or enter a Date.
  • Problem: Select a Problem from the Drop-Down Menu

  • Complete any additional fields in the window. Always follow your practice policy.

Tip: It is recommended when clicking the Drop-Down Menu in the Problem field, the list displays only valid SNOMED codes. When selecting the correct problem for a documented disease choose a single antigen, for example, if documenting measles you would select Measles (disorder).

  1. Click the Save button.

Documented Immunity Display

When a vaccine immunity has been documented, there are areas in OP that display the information. This includes a warning prompt if an order is created for the immunization and the task for a vaccine immunity is opened.

  • Indicators > Historical Status Indicators: The Indicators tab updates when a documented disease or documented immunity is entered for a patient in the Problem List.

WarningThe Historical Status Indicators are for reference only and you are unable to edit or add information from this window. You may delete from this window to clean up old indicators.

  • Complete List: The Complete List will update when a documented immunity was entered in the Problem List.

  • Forecast: The vaccine forecast for the immunization will update and display Documented disease or Documented immunity. 
    • Documented disease displays when the selection in the problem list SNOMED was disorder.
    • Documented immunity displays when the selection in the Problem List SNOMED was finding

  • Charting Warning: The Warning window below is displayed when selecting a vaccine that has a documented immunity. The Warning window is displayed when selecting the vaccine from the Plan/Orders tab during charting of a visit.

  • Complete a task: The Warning window is displayed when selecting to complete a task for a vaccine that has a documented immunity.