Overview

The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Example

Juana Mariana Gonzales, age 6, received live, attenuated influenza vaccine on November 9 at a local pharmacy.  His mother brought a copy of the vaccination information to the office and Dr. Smith entered it directly into the EHR system even though the vaccine lot number and expiration date were missing.  Reviewing Juana Mariana’s record one month later, Dr. Smith’s associate is able to see that the November 9 influenza vaccine was manually entered and identify the source of the information (in this case, the patient’s mother).

Guidance

The capability addresses recording immunization history obtained from external sources or history provided by the patient or patient’s caregiver. The available fields for capturing the information should be the same as listed in the section associated with capability 2.4 (including a field to indicate the source of the information (i.e., the registry, the patient, etc.). All vendors evaluated consistently supported the historical vaccine name, CVX, date, and lot number.

• Vendor, Provider and Implementer Perspectives. Products with the ability to identify the source of historical information may assist providers to perform reconciliation. Additional data (such as administered at location) may also allow providers to obtain additional information as needed for vaccine recalls.

Test

Click here for test script scenarios that include the capability, Record Past Immunization. The script also indicates successful performance for each of the test sections.

Data Elements

The data elements include the immunization history data specific to the clinical scenario in the test script.