Immunization

Vaccination records, held in enough detail to report to an immunization registry.

Recording a vaccination

Field	Records
Vaccine type	From the CDC CVX code set — around 75 entries, each shown as code and name, e.g. 20 – diphtheria, tetanus toxoids and acellular pertussis vaccine
Full vaccine name
Dose number	Which dose in the series, 1 to 10
Administered	Date and time given, and the amount in ml, mg, mcg, iu, drops, puffs, or other units
Route and Site	How and where it was given, from coded lists
Lot number, expiration date, manufacturer
CPT code	For billing
Ordered by and administering provider
Administration notes

Lot number and expiry are not optional detail

If a vaccine lot is later recalled, the lot number is what tells you which of your patients received it. It takes a moment at the time and is unrecoverable afterwards.

When a vaccine isn't given

The record also handles the cases where a vaccination did not happen:

• Substance refusal reason — with room for additional text
• Presumed immunity to the disease

Record refusals as deliberately as administrations

A refusal recorded as a refusal is a documented clinical conversation. A refusal recorded as nothing at all is indistinguishable from never having offered it.

Registry and funding fields

Several fields exist specifically for reporting rather than for your own chart:

Field	Purpose
Immunization registry status	The patient's status with the registry
Publicity code	How the record may be used for reminder/recall
Vaccine funding program eligibility	Which programme covered the dose
Protect data	Restricts sharing of the record

Vaccine Information Statement

The VIS — the CDC's patient information sheet for that vaccine — is tracked with the record.

Giving the VIS is a federal requirement

Federal law requires that the current Vaccine Information Statement is given before certain vaccinations, and that the fact is documented. Recording which VIS applied is how that is evidenced.

Exporting

Two exports are available:

• Immunization HL7 — the record in HL7 format for submission to an immunization registry
• Syndromic HL7 — for syndromic surveillance reporting

HL7 is the required format, not a convenience

Electronic submission to immunization registries is expected in HL7, which is why the record carries coded values rather than free text throughout. The coding is what makes the export usable at the other end.

Editing

Records track who entered them and when, and separately who last modified them and when — so a correction is visible as a correction.