Patient Immunization Record (Page 2 of 2) in pdf

How to use MDH’s Patient Immunization Record form

Make this record easily accessible

Hx of vaccine reaction (history of vaccine reaction)

Keep each patient’s immunization record where you can easily review it

If the patient has experienced a clinically significant or unexpected event

during each office visit (e.g., the front inside cover of the patient’s medical

after an immunization (even if there is uncertainty that the vaccine caused

chart).

the event), place a ü in the “Hx of vaccine reaction” column. Provide more

specifics about that event elsewhere in the patient’s chart. Report vaccine

Patient behind schedule?

reactions to the Vaccine Adverse Events Reporting System

Flag the record if the patient is behind on recommended immunizations.

( or 800-822-7967).

Record type of vaccine

Transferring immunization information onto this form

Be sure to indicate the type of vaccine you gave. This is especially important

Transfer vaccine information that patients receive at other clinics to this

when you give DT-pediatric rather than DTaP since children who receive

record. If you don’t know all of the information, record at least the date (mo/

DT-pediatric will be at higher risk of pertussis disease if there is a pertussis

day/yr) and type of vaccine. The responsibility for maintaining the federally

outbreak in the community.

required information is with the clinic that administered the vaccine. Be

What information is required by federal law?

sure to place a ü in the “Given elsewhere” column. If a patient transfers to

You are required by federal law to record the following information as part of

another clinic, provide a photocopy to the new clinic.

the National Childhood Vaccine Injury Act, even if you administer a vaccine

Use the MIIC registry to record and find immunizations

to an adult patient:

If you’re participating in the Minnesota Immunization Information Connection

• Manufacturer and lot number of vaccine given.

(MIIC), be sure to enter or submit data on new shots for this patient so it is

• Date vaccine given.

available to others who may be giving subsequent doses. MIIC is located at

• Date of publication of the Vaccine Information Statement (VIS) and

https://miic.health.state.mn.us. If you are not yet participating, call

the date the VIS was given to the vaccinee (or parent or legal

800-657-3970, or visit (click on “MIIC

representative of the minor child).

Registry”) to find out how to enroll.

• Name, title, and address of the person who administered the vaccine.

Manufacturers’ codes

Note: Federal and Minnesota laws do not require written informed consent.

Use the codes listed in the chart below to indicate the manufacturer of the

However, some clinics may have their own policy.

vaccine. These are the same codes used universally and by the Minnesota

How to record combination vaccines

Immunization Information Connection (MIIC).

Record a combination vaccine under each specific antigen that the vaccine

Vaccine Manufacturer

Code

contains. Use a hyphen between each antigen. Examples:

CSL Biotherapies

CSL

• TriHibit is DTaP-Hib. Record it under both DTaP and Hib.

GlaxoSmithKline

SKB

• Comvax is Hep B-Hib. Record it under both Hepatitis B and Hib.

Massachusetts Biologic Labs

MBL

• Pediarix is DTaP-IPV-Hep B. Record it under DTaP, IPV, and Hepatitis B.

MedImmune, Inc.

MED

How to record injection routes and sites

Merck & Co., Inc.

MSD

The most common routes for vaccination are intramuscular (IM) and

subcutaneous (SC or SQ). Less frequent routes include oral (PO) and

Novartis

NOV

intranasal (ITN). If there is more than one choice for route, circle the route

sanofi pasteur Inc.

PMC

given. Sites for injections should be noted as to which limb and what side.

Wyeth Vaccines

WAL

These include right thigh (RT), left thigh (LT), right arm (RA), and left arm

Your patients need personal immunization record cards

(LA).

Always update the patient’s personal immunization record with information on

Immunization Program

the vaccines that you administered. If your clinic needs personal immunization

P.O. Box 64975

record cards, order the MDH Gold Card by calling 800-657-3970, or 651-201-

St. Paul, MN 55164-0975

651-201-5503 or 1-800-657-3970

5503, or by filling out the order form at .

Patient Immunization Record Page 2

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