9.3.5.5: Vaccine Administration Documentation
- Page ID
- 90383
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In addition to documenting the presentation of the VIS to the patient or the patient’s guardian, there are other items that the MA must legally enter into the patient’s health record. The National Childhood Vaccine Injury Act mandates that the following must be documented in the patient’s health record.
- Date of administration
- Vaccine manufacturer
- Vaccine lot number
- Name and title of the person who administered the vaccine and address of the facility where the permanent record will reside
- Vaccine information statement (VIS)
- Date printed on the VIS
- Date the VIS was given to the patient or parent/guardian
Most facilities also require the MA to document the site of vaccine administration and the patient’s response (National Center for Immunization and Respiratory Diseases, 2019).