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HOW TO DOCUMENT IMMUNIZATIONS IN THE MEDICAL RECORD

To ensure patients are fully immunized and to reduce missed opportunities to vaccinate, medical providers must be able to assess an immunization record quickly at every patient visit.

Documenting all doses of vaccine in a single location in the medical record is a universally recommended practice. Providers are encouraged to use the Immunization Record and History Form to record all immunizations given. This form was developed by the Vaccines for Children Program (VFC) to help medical providers document all vaccine information in one location in the patient's medical record. The form may be used for all patients whether or not they qualify for the VFC Program.

Federal law requires that all healthcare providers record in the patient's medical record the following:

patient's name and date of birth
type of vaccine (s) given
clinic/office address
date of administration
vaccine manufacturer and the lot number of the vaccine used
name and title of person administering the vaccine
injection site
date of publication of appropriate Vaccine Information Statement (VIS) given and the date the VIS is given to the patient or parent, if patient is a minor

The information on this website should not be used as a substitute for the medical care and advice of your healthcare provider. Your healthcare provider may recommend variations in treatment based on individual facts and circumstances.