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11. Documentation

Objectives

a. Describe federal requirements for documentation related to the administration of vaccines.
b. Describe additional state and local requirements for documentation related to the administration of vaccines.
c. Describe best practices for documenting vaccine administration.
d. Describe best practices for documenting vaccine refusal.
e. Describe best practices for documenting vaccine contraindications and precautions.
f. Explain the benefits of using an immunization information system (IIS) (see ​Topic 2–Immunization Strategies).
g. Describe how to document an adverse event (i.e., anaphylaxis) following vaccination..
h. Describe nursing roles and responsibilities related to documentation: vaccine administration or supervision of vaccine administration, advocate, records manager, educator, and lifelong learner.

Resources

Web pages
American Academy of Pediatrics (AAP)–Immunization: Refusal to Vaccinate
  • www.aap.org/en-us/advocacy-and-policy/ aap-health-initiatives/immunization/Pages/refusal-to-vaccinate.aspx

CDC Vaccines and Immunizations
  • About Immunization Information Systems
    ​www.cdc.gov/vaccines/programs/iis/about.html

  • ACIP: Acronyms for Vaccines
    ​www.cdc.gov/vaccines/terms/vacc-abbrev.html

  • Standards for Practice: Vaccine Documentation
    ​​www.cdc.gov/vaccines/hcp/adults/for-practice/standards/ documentation.html

EZIZ–Vaccine Administration job aids: Documentation
  • http://eziz.org/resources/vaccine-admin-job-aids/

​Immunization Action Coalition (IAC)–Clinic Resources: Documenting Vaccinations
  • ​ ​​www.immunize.org/clinic/documenting-vaccination.asp
Handouts
American Academy of Pediatrics (AAP) website–Documenting Parental Refusal to Have Their Children Vaccinated
  • https://www.aap.org/en-us/Documents/immunization_refusaltovaccinate.pdf 

IMMUNIZATION ACTION COALITION (IAC)
  • Screening Checklist for Contraindications to Vaccines for Adults
​          www.immunize.org/catg.d/p4065.pdf

  • Screening Checklist for Contraindications to Vaccines for Children and Teens​
          www.immunize.org/catg.d/p4060.pdf
LEARNING MODULES
CDC Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book) webinar series–Vaccine Storage and Handling and Administration
  • www.cdc.gov/vaccines/ed/webinar-epv/index.html

​Nursing Initiative Promoting Immunization Training (NIP-IT) Module 5: Vaccine Administration: Vaccine Documentation Components
  • nip-it.org/vaccine_administration.asp
BOOKS
  • American Academy of Pediatrics. Active and Passive Immunization. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases, 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:1–111.
  • CDC. Vaccine Administration. In: Hamborsky J, Kroger A, Wolfe S, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th ed. Washington, DC: Public Health Foundation; 2015:79–105. Available at www.cdc.gov/vaccines/pubs/pinkbook/vac-admin.html.
  • Fraser, D. Health Problems of Infants. In: Hockenberry MJ, Wilson D, Rodgers CC, eds. Wong’s Essentials of Pediatric Nursing, 9th ed. St. Louis, MO: Elsevier Health Sciences; 2012:228–307.
  • Ricci SS. Newborn Management of the Newborn. In: Ricci SS. Essentials of Maternity, Newborn, and Women’s Health Nursing, 4th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2017:585–644.
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  • Home
  • Topics
    • 1. Public Health Perspectives
    • 2. Immunization Strategies
    • 3. Immune System/Immunology
    • 4. Vaccine-Preventable Diseases
    • 5. Types of Vaccines
    • 6. Immunization Schedules
    • 7. Communications
    • 8. Legal/Ethical Issues
    • 9. Vaccine Storage and Handling
    • 10. Vaccine Administration
    • 11. Documentation
    • 12. Vaccine Safety
  • Resources
  • Background
  • Feedback