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Q:
Am I required to keep a photocopy of patient's California Immunization
Record?
A: Keeping a photocopy of the California Immunization Record
in the medical chart, while helpful to some providers, is not required
by the state. MediCal, CHDP and VFC auditors do require documentation
of a patient's complete immunization history. For all patients immunized
in your office, document all shot data on the Immunization
Record and History Form. Having multiple copies of the California
Immunization Record in various stages of completion in the medical
record is discouraged, since it makes assessment difficult and time
consuming. Some health plans may currently require a copy of the
CIR. However, as providers routinely use the Immunization Record
and History Form, this may change.
Q:
Am I required to keep a separate vaccine log?
A: Keeping a vaccine log separate from the patient's permanent
medical record may be useful in the event of a vaccine recall, but
it is not required by MediCal, CHDP or VFC.
Q:
Do I have to obtain written consent from parents or guardians?
A: There is no federal or California requirement that written
consent be obtained from the parent/guardian for each immunization
given. However, legal opinion states that the healthcare provider
has a duty to disclose pertinent information based on a complete
understanding of the inherent risks associated from the vaccine
to the vaccinee or a legal representative prior to the administration
of vaccine. Documenting the VIS publication date (space provided
on the Immunization Record and History Form) and the date it was
distributed is required and considered evidence of disclosure.
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