How to Input an Immunization Record

Patient immunization records provide up-to-date information regarding the type, location and date of the administration of immunizations. Health care facilities provide immunizations to the patient population in an effort to prevent the spread of infectious disease. Health care facilities also assign record-keeping responsibilities to administrative professionals and technicians following each successful administration. The proper annotation of medical records requires the validation of immunization notes and the proper input of information in either digital or physical medical records. Each facility must require strict attention to detail when updating immunization records.

Instructions

• 1

  Verify the form. Check the immunization form number and circulation date in the bottom right hand corner to ensure the version is valid.

• 2

  Look at the immunization notation to ensure the physician, nurse or technician annotated the name of the immunization (i.e. measles, mumps, rubella), the dosage administered (i.e. 5cc) and the type of administration (i.e. intradermal).

• 3

  Verify the consent form. When a patient consent form accompanies the immunization record, verify the presence of the patient's full signature, the attending physician's signature and the date of immunization.

• 4

  Input the record. Create a record of the immunization in an electronic medical file or a physical medical record jacket. For electronic records, verify that the Social Security Number on the immunization form matches the number on the screen, then input the patient's name, immunization date, type of immunization and attending physician's name. For physical records, record the above information on an existing immunization form in the file, or create a new record on a blank form or new immunization form.