1. Document Name: Vaccine AdministrationandDocumentation
Document Type: STANDARD OPERATING PROCEDURE
Department: Continuous Improvement
Authored By: Tara Sauers
Clinical Operations OMT
Approved By:
Date:
BarryMagnus, MD
Vice President for Medical Operations East Zone
04/01/2015
RevisedBy: Name
Title
Revision Approved By:
Date:
Name
Title
MM/DD/YYYY
Stakeholders: Clinical Operations
Change Summary: New
Next Review Date: 04/01/2016
Line of Business: Clinical Operations
Role(s): Medical Support Staff, Nurse, X-RayTechnician, Clinician
Prerequisites
The followingis necessarybeforethe procedurescontainedinthisguidecanbe successfullycompleted:
Medical SupportStaff (MSS)/Nursesmustcomplete the Medication AdministrationClinical
Competency.
Background
The purpose of this Standard OperatingProcedure (SOP) istoinformMSS/Nursesaboutcorrect
operational patientservice processes ̶ includingVaccine Administration.
For Travel Healthor Influenzaonlyvaccineservices, refertothose specificprocessfordocumentationof
vaccine administered
Pediatricprimarycare facilities administeringvaccinesforchildren lessthan7years oldare not
includedonthe Vaccine AdministrationRecord
Facilitiesthatreceivepediatricvaccinesthrough VaccineForChildren(VFC) andotherprograms
have differentoradditional state guidelines forthe documentationof vaccines.
Individual statesmayhave additional ordifferentrequirements thatpertaintoVaccine
Administration documentation,whichmustbe followed.
Note:MSS and nursesmay only administervaccineswhere allowedbyfederal,state, andlocal
regulations.
2. Vaccine Administration and Documentation
Confidential – Internal Use Only
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Process Overview
Procedures
Step 1: Back Office ̶ Prepare/Provide the required Vaccination and Consent Forms
Complete the following stepstoprovidethe patientorparent/legal guardian withthe correct
documents andconsents needed tocomplete Vaccine Administration.
1. MSS/Nurse/Clinician reviews admission documents orworklistorder, andpreparesthe forms.
If... Then…
The patientisin the waitingroom MSS/Nurse/Clinician preparesdocumentsprior
to callingthe patient
If the patientisalreadyina treatmentroom
for injury/illnessornon-injury care
MSS/Nurse/Clinician prepares the
documents ̶ afterthe clinicianexaminesthe
patient,asindicatedbythe worklist or
clinicianorder ̶ before enteringthe
treatmentroom
2. Required Vaccine Administration formsinclude:
a. Vaccine Disclosure and InformedConsent (VDIC)
b. Vaccine InformationStatement (VIS)
c. Vaccine ScreeningQuestionnaire(VSQ)
d. Vaccine Administration Record(VAR)
Note:Separate VARsandVSQsforms forminors.
Step 1: Back Office ̶
Prepare/Provide the
requiredVaccination &
Consent Forms
Step 2: Back Office &
Clinician ̶ Review
Vaccine Screening
Questionnaire to
determine next steps
Step 3:ClinicianReviews
& Signs the Vaccine
Administration Record
(VAR)
Step 4: Back Office ̶
Staff/Clinicianprepares
Vaccine
Step 5: Back Office ̶
Staff & Clinicianobtain
Patient's Consent and
administer Vaccine
Step 6: Back Office ̶
Provide Post-Vaccination
Care andcomplete
VAR
Step 7: Front Offi ce ̶
Complete CheckOut
3. Vaccine Administration and Documentation
Confidential – Internal Use Only
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3. MSS/Nurse/Clinician provides the patientorparent/legal guardianwiththe required
documents:
VIS
VSQ
Note:The VARand VDICare notgivento the patientorparent/legal guardianatthistime.
4. MSS/Nurse/Clinician allowsthe patientorparent/legalguardianenoughtimeto review,
complete,andsignVaccine Administration documents.
Note:MSS maychoose to leave the examroom duringthisstep.
5. MSS/Nurse/Clinician retrievesthe completed/signedVSQfromthe patientorparent/legal
guardian.
6. Note: Onlyquestions1-10on the VSQmust be completedforstandardvaccinations. Questions
11-19 onthe VSQ apply onlyto Travel Healthvaccinationservices..
Step 2: Back Office ̶ MSS/Nurse and Clinician review the VSQ to determine next steps
Complete the following stepsforclinicianreviewof the VSQ.
1. MSS/Nurse givespatientformstothe clinicianincluding:
a. CompletedandsignedVSQ
b. VAR
i. Fieldscompletedonthe VARatthistime include:
o PatientName
o PatientDate of Birth
2. Clinician reviewsandsignsthe VSQ.
3. If the Cliniciandeterminesthatmore evaluationisneededbasedonthe VSQ1
:
Patientorparent/legal guardianare toldthatthe clinicianwillreview the VSQ withthem
Additional admissionforthisservice is notrequired
The clinicianadvises the nextstepstothe MSS/Nurse and patient,orparent/legal guardian
If… Then…
Clinicianfindsthatvaccinationcannotoccur The vaccine is notgiven
The cliniciandirectsthe patient,parent,
or legal guardiantofollow upwith their
PrimaryCare Physician(PCP) with
appropriate documents
If admissionoccurredinOccuSource,
Front Office Specialist(FOS) walksout
visit,nocharge for service
4. Vaccine Administration and Documentation
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If admissionoccurredinGE Centricity,
FOS will checkthe visitoutof GE withthe
correct billingexception,if applicable and
vaccine onlyservice
Contact employerasdetailedin the
service package/employernotes
Cancel orderin Allscripts,viathe "entered
inerror" function,if applicable
Clinician determines thatavaccinationcan
occur:
Cliniciansignsthe VSQ2
ProceedtoStep3
1 ̶ See Vaccine ScreeningQuestionnaire Clinical Protocol inResources
2 ̶ See Medication& Vaccine Administration andPolicySetinResources
Step 3: Clinician Reviews and Signs VAR
Complete the followingstepstoprovidethe MSS/Nurse withthe clinician'sorderforthe vaccine:
1. Clinicianreviewsthe VAR.
2. Cliniciansignsanddatesthe correspondingline forthe vaccine the patientwill receive3
.
Note:The VARsignedbythe clinician isanorderfor vaccination fornon-injury services.Forinjury/illness
services, workorderrequestsmustbe documentedin Allscripts, inadditiontothe VAR.
3 ̶ See the Resourcessectionforclinicianordersignature imageon the VAR.
If... Then…
There isan acceleratedoptionfor the
vaccinationschedule
Clinicianshouldcircle the appropriate column
underschedule onthe VAR
Vaccine isa rabies vaccine Clinicianindicateswhethervaccine isfor
pre-exposure orpost-exposure
(SeeVaccination Administration Record Clinical
Protocolin Resources)
Vaccine isa series ̶ where follow-up
vaccinationsare required
Patientorparent/legal guardian isinformedof
timingrequirementsforvaccine series
Vaccinationisa followupthatispart of a series Ensure the propertime has elapsedsince
previousvisit
Withclinicianapproval,vaccinesmay be
administeredupto fourdays earlierthan
recommended interval
Withclinicianapproval,vaccinesmaybe
administeredlaterthanscheduled
(SeeVaccination Administration Record Clinical
5. Vaccine Administration and Documentation
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Protocolin Resources.)
Vaccine isnot a pre-populatedoptiononthe
VAR
Hand write immunizationsthatare ordered,but
not pre-populatedonthe VAR
Step 4: Back Office ̶ MSS/Nurse/Clinician prepares Vaccine following the Administration
Guideline
Complete the following stepstoprepare the vaccine tobe administered:
Note:MSS and nursesmay dispense vaccinesonlywhereallowedbyfederal,state, andlocal
regulations.
1. Confirmclinician's orders
2. MSS/Nurse/Clinician createsorderin Allscripts,if service is vaccine only
a. See Allscripts StandingOrderQuickGuide formore information
3. Readlabelsand note:
a. Medications thatmay have similarnamesorpackaging
b. Look alike andsound-alike vaccines
c. Medications thatare not commonlyusedorprescribed
d. Commonlyused vaccines towhichmany patientsare allergic(e.g.,antibiotics,opiates,
and nonsteroidal anti-inflammatory drugs)
e. Checkexpirationdate
f. Double-checkdosage,route,andcalculationspriorto administering the vaccine
g. Properhandwashingandaseptictechnique shouldbe usedatall times(Referto
InfectionControl protocol)
h. Use correct equipment forpreparationof vaccinationorvaccine (e.g.correctdiluent)
4. Prepare the vaccine toadminister(permanufacturer'sguidelines)
The clinicianordermustbe verifiedbyadditional MSS/Nurse/Clinicianpriorto
administration
Vaccines mustbe verifiedbyadditionalmedicalsupportcolleaguesorclinicians, priorto
administration
If … Then…
Vaccine administration will documentedin
Allscripts
Documentthe vaccination andclinician
order ̶ as verifiedbythe additional
MSS/Nurse/Clinician ̶ by selectingthe
colleague whocompletedthe verificationin
the drop-downselectionbox inthe "Visually
VerifiedBy"sectionof the record
administration
(SeeResources section below for image)
Vaccine Administration will not be
documentedin Allscripts
Additional MSS/Nurse orclinicianwill initial
nextto clinicianorderbox of VAR,indicating
theyhave completedsecondary medication
and orderverification
6. Vaccine Administration and Documentation
Confidential – Internal Use Only
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Step 5: Back Office ̶ Staff and Clinician obtain Patient’s Consent and administers Vaccine
Following the Administration Guidelines
Complete the followingstepsinordertocomplete VaccineAdministration:
1. The patientor parent/legal guardiancompletes the VDIC.
a. Patientorparent/legal guardianinitialsthe "accept"portionof the VDIC
Note:If the patientor parent/legalguardiandeclinesthe vaccine,the clinicianshouldbe informed.
Moreover,the patientorparent/legal guardianinitials shouldbe inthe decline portionof the VDIC
form.
b. Patientorparent/legal guardianandwitness signaturesanddate of service mustbe
completed to proceed with Vaccine Administration
c. Askthe Patientor parent/legal guardianif theyhave anyquestionsto discuss withthe
clinician, priortoadministering the vaccine
2. Askif the patientorparent/legal guardianhasahistoryof syncope/fainting orpre-syncope
If... Then…
Patientindicatestheyhave ahistoryof
syncope/faintingorpre-syncope
Informpatientorparent/legal guardian
that the MSS/Nurse/Clinician givingthe
vaccine will observe the patientfor5
minutes post-vaccinationinthe exam
room forsafetyconsiderations
Instructthe patientorparent/legal
guardianthat we will request they
waitin the checkout/lobbyareafor10
minutes post-injection;toreportany
additional symptomsthatmayoccur as
a potential reactiontothe vaccination
Educate the patientorparent/legal
guardianto reportany symptoms
immediately
Patientindicatestheydo nothave ahistory
of syncope/faintingorpre-syncope
Instructthe patientorparent/legal
guardianthat we will requestthey
waitin the checkout/ lobbyareafor15
minutespost- injection;inorderto
reportany additional symptoms that
may occur as a potential reactionto
the vaccination
Educate patientor parent/legal
guardianthat anysymptomshouldbe
reported rightaway
7. Vaccine Administration and Documentation
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3. Verifycorrectpatientorparent/legal guardianbyaskingfull name anddate of birth
4. Recheckforallergies
5. Use the 7 Rightsof Medication Administration4
before givingthe vaccine
a. The Right Patient
b. The Right Drug or Vaccine
c. The Right Dose
d. The Right Route
e. The Right Time
f. The Right Site
g. The Right Documentation
4 ̶ See Medication&Vaccine Administration Policy SetunderResources
6. Administerthe vaccine(s)tothe patientfollowingMedicationAdministrationguidelines,
regulatoryrequirements,andclinical competencyguidance
a. Clinical CompetencyMedicationAdministration
Step 6: Back Office ̶ Provide Post-Vaccination Care Instructions and complete VAR
1. Patientorparent/legal guardianreceivespost-vaccinationinstructionsfromthe
MSS/Nurse/Clinician
a. Post-vaccine instruction isdeterminedby the patient's history of syncope/faintingor
pre-syncope
If... Then…
Patienthasa historyof syncope/fainting or
pre-syncope
Observe patientone-onefor5 minutespost-
vaccine
If… Then…
No symptomsoccur
after5 minutes
Escort the
patienttothe
waitingroom
withinstructions
to waitanother
10 minutes
duringcheckout
Advise patient
or parent/legal
guardianof time
vaccine given
Symptomsoccur
after5 minutes
Call clinicianSTAT
and follorthe
Allergic&
Anaphylactic
Reactionsfollowing
8. Vaccine Administration and Documentation
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Medicationor
Vaccine
Administration
Clinical Protocol
Patienthasno historyof syncope/fainting
or pre-syncope
Requestthe patient waitincheckoutarea
for 15 minutes post-vaccine totoallowfor
rapidassistance if new symptomsdevelop
Advise patientorparent/legal guardianof
time vaccine given
Instruct patientorparent/legal guardianto
reportany symptomsto FOS at checkout
If… Then…
Patientreportsany
symptomstoFOS
Immediatelynotify
the
MSS/Nurse/Clinician
2. Complete Vaccine Administration Documentation inAllscripts (if applicable) andon paperVAR
a. Documentationincludescompletionof VAR
i. Date vaccine andVISgiven
ii. Applicable schedule dates/seriesnumbercompleted
iii. VISversiondate
iv. Vaccination Dose
v. Vaccination Route
vi. Vaccine Information
o Manufacturer
o Lot Number
o ExpirationDate
vii. Site
o Hemisphere
o BodyPart
viii. Administered by:SignatureandDate
ix. ClinicianOrder: Signature andDate
x. Vaccination andordersecondaryverification
3. Scan all completed/signed documentsinto Allscripts,“patientinformation”folder,if applicable
4. If vaccine-only service, clinician will receive a Submit Res Enc Task to submit the charge in
Allscripts
5. Printelectronicvaccinationrecordfrom Allscripts,if applicable
6. Provide HepatitisBWalletCardwith follow upschedule datespopulated,if applicable
7. Escort patienttofront office forcheckout
Step 8: Front Office ̶ Complete Check Out
Complete the followingsteps tocompletethe checkoutprocessforservicesincluding Vaccine
Administration.5
9. Vaccine Administration and Documentation
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Note:Checkout may occur inback office,if fast-trackservice occurred.
1. FOS completescheckout
2. FOS photocopiesthe completedVARand providesacopyto the patientorparent/legal
guardian
3. If patientor parent/legal guardianreportsanysymptomsto FOSduringcheck out, they
mustensure patientsafetyand notifythe MSS/Nurse/Clinician forimmediateassistance
5 ̶ See Site OperationsCheck OutPlaybook inResources
Terms
Term Definition
FOS Front Office Specialist
MSS Medical Support Staff
Syncope Temporarylossof consciousnesscausedbyafall inbloodpressure
VAR Vaccine Administration Record
VIS Vaccine InformationStatement
VSQ Vaccine ScreeningQuestionnaire
VDIC Vaccine Disclosure andInformedConsent
Resources
1. Refertothe following linksforadditionalinformation:
AllergicandAnaphylacticReactionsFollowing VaccineAdministration Protocol
Allscripts QuickGuide - ImmunizationStandingOrder
Clinical Competency - MedicationAdministration
Medication & VaccineAdministration Policy Set
Site OperationsPlaybookCheckInChapter
Site OperationsPlaybookCheckOutChapter
Vaccine Administration Clinical Protocol
Vaccine Administration RecordClinical Protocol
Vaccine Administration Record(Adult)
Vaccine Administration Record(Pediatric)
Vaccine Disclosure andInformedConsent
Vaccine Disclosure andInformedConsentClinicalProtocol
Vaccine InformationStatementClinicalProtocol
Vaccine ScreeningQuestionnaireClinical Protocol
Vaccine ScreeningQuestionnaire–Adult(English)
Vaccine ScreeningQuestionnaire–Children&Teens(English)
10. Vaccine Administration and Documentation
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2. Helpful FormHints
o Clinicianreview of the VSQisindicatedbythe cliniciansignature presentonthe
"Form Reviewedby"line
o Clinicianorderforvaccinationisindicatedbythe cliniciansignature onthe VAR
o VaccinationandOrdervisuallyverified byadditional MSS/Nurse/ClinicianorClinicianin
Allscripts