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Documentation and Coding Guidelines for Public Health Nurses Immunization Documentation Example #2 The nurse documents the chief complaint and the vital signs of a child who presents with mother for an immunization update, as shown in the Chief Complaint dialog box below. The nurse uses the Reminder Resolution dialog box (shown below) to document vaccine administration in the EHR note and elsewhere. If your reminder dialog does not contain a full SOAPIE note format, you may either type in your note or use a separate template to document your assessment, then process the clinical reminder dialog immediately after that in the same note. Indian Health Service Page 5-22
Documentation and Coding Guidelines for Public Health Nurses Resulting Note The following note is the result of Immunization Documentation Example #2. The note is authenticated using the Identify Additional Signer function. S: Chief Complaint: Patient presents with mother for immunization update. Screened and no contraindication for today's immunizations which are given by per standing order. O: TMP:98.20 (36.7 C), PU:80, RS:16, BP:100/60, WT:88.18 (40.04 kg) A: Immunization Update P: ***** CLINICAL REMINDERS ACTIVITY ***** Td/Tdap: Tdap Immunization information. Patient received Tdap immunization at this visit per standing order Lot Number: AC2B054BA Imm Site: Left deltoid im Injection Volume: 0.5 Vacc Info Sheet Date: November 18, 2008 /es/ Jane Smith, RN Registered Nurse Signed: 04/26/2011 08:52 Receipt Acknowledged By: 4/26/2011 12:22 /es/ Susan Pierce-Richards, ARNP Nurse Practitioner Authentication of an Implemented Immunization Standing Order Immunization standing orders must be authenticated, with the exception of influenza and Pneumovax. See the Authentication of an Implemented Standing Order subsection above under Section 5.4. Indian Health Service Page 5-23
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