How To Record Immunizations In Healthteam

Transcription

1 Electronic Medical Records (EMR) NEW IMMUNIZATIONS

2 NEW IMMUNIZATIONS Purpose The intent of this document is to instruct HealthTeam staff and providers on the process used to record immunizations newly administered to HealthTeam patients, using templates available in Centricity EMR. Table of Contents DOCUMENTING NEW IMMUNIZATIONS 1 CHECKING FOR IMMUNIZATIONS ALREADY DOCUMENTED 1 USING A NEW ENCOUNTER TO RECORD IMMUNIZATIONS 2 Ending the Update 5 AN IMMUNIZATION FORM EXAMINED 7 Name and Age Checks 8 VFC Eligibility 8 Selecting the Correct Number in an Immunization Series 8 Intervals 10 Consent or Decline 11 Details of the Immunization Administered 13 The Second Tab 16 DOCUMENTING IMMUNIZATIONS IN BRIEF 17 Safety Point If an immunization is recorded in the patient s Centricity chart multiple times, it is difficult to determine not only what has actually been administered, but also what additional immunizations the patient may still need. The best way to prevent errors is to use extreme caution when documenting all immunizations in Centricity both historic and those actually administered at the time of the chart update in which it is being recorded. Prepared by Michigan State University EMR Revision Date: 9/29/09 MLNewImmunizations.doc

3 DOCUMENTING NEW IMMUNIZATIONS The process of documenting newly administered immunizations given at a HealthTeam clinic is not the same as when documenting immunizations given elsewhere, or at a HT clinic during a previous visit. Also, the forms used to document newly administered immunizations vary, depending upon the patient s age at the time of the visit, and the actual immunizations given. The primary forms used to document such immunizations are: Immunizations Menu Adult or Immunizations Menu Pediatric, and the immunization-specific forms (ex: the Varicella form, or Zostavax form). Also, depending on the immunization form being used, various cross-checks are made in the background, such as recommended age parameters, time intervals between doses administered, instances of the immunization already in the patient s record, etc. These cross-checks and their associated text displays are intended to assist the person(s) responsible for making immunization administration decisions; they do not replace the need for careful consideration on the part of the clinician making the final immunization administration decisions. Safety Point Always make sure that the immunizations you intend to record have not already been recorded in the patient s Centricity chart. CHECKING FOR IMMUNIZATIONS ALREADY DOCUMENTED Before recording immunizations in a patient s Centricity chart, check to verify that those immunizations are not already there. If they have already been recorded, do not enter them again. A few, but not all, methods for checking for previously documented immunizations are listed below. For more detailed instructions, see the Historic Immunizations training video and/or its accompanying documentation. On the Documents tab of the patient record, look for immunizations that may have already been documented in another chart update in the patient s Centricity chart that has yet to be signed. Make sure immunizations you are about to record have not already been documented in another unsigned chart update. Select the All Immunizations View on the Flowsheet tab of the patient s chart. Scroll as needed to view immunizations already entered and signed in the patient record, up and down for the various immunization, and left to right, to scan through the years of treatment. Note: Immunizations documented in another chart update that has not yet been signed will not appear on the flowsheet. View the All Immunizations Flowsheet Prepared by Michigan State University EMR 1 of 17

4 Check either the Immunizations Report or the Immunizations Comprehensive handout. As with the flowsheet view, immunizations entered in an update that is On Hold will not appear in these handouts, so be sure to check the Documents tab for any unsigned notes, too. For more about the Immunization Handouts in Centricity, see the training documentation for Viewing and Printing Immunizations. Preview either the Immunization Report or Immunizations Comprehensive handout USING A NEW ENCOUNTER TO RECORD IMMUNIZATIONS Once you have verified that the immunization(s) newly administered to the patient have not already been documented in his or her Centricity chart, you can do so either in an existing chart update, or begin a new, immunization-specific chart update. We will look at the process of starting a new encounter to document the new immunizations, using first Tdap, and later Hepatitis B, as examples. 1. Locate and open the patient chart. 2. Click on the Update button, in the upper right portion of the chart window. 3. In the Update Chart window, select the Immunizations Encounter Type. Select Immunizations 4. Select the appropriate Provider from those available in the Provider: dropdown list. 5. Change the Summary: to show that newly administered immunizations to be documented. (The text to be added varies, per clinic-specific documentation standards.) 6. Click Ok. Prepared by Michigan State University EMR 2 of 17

5 7. Depending on the patient s age, either the *Immunization Menu - Pediatric or *Immunization Menu Adult form opens. These two forms share many buttons that, when clicked, pull an immunization-specific templates, to be used to document immunizations administered in HealthTeam clinics. 8. Following the Tdap example, click the Tdap button to bring that form into the chart update. Click the Tdap button The *Immunization Menu Pediatric Template When you click a button on the Immunization Menu form to bring another form into the current chart update, the word Added appears in the display directly to the left of the button just clicked, and the Next Form (Ctrl + PgDn) button becomes activated. 9. Click the Next Form (Ctrl + PgDN) button to navigate to the Tdap form and continue the immunization documentation process. Prepared by Michigan State University EMR 3 of 17

6 10. The Tdap form opens, with the patient s name displayed in its blue title bar. Beneath the title bar you see fields where you can record the patient s Vaccine for Children (VFC) eligibility. If VFC information has been recorded in the patient s chart during a previous chart update, it is displayed, and you can leave it as is, or modify it, as needed. 1 a. If you want the VFC information to appear in the text of the chart update, put a checkmark () in the checkbox to Include VFC Information in the note. b. The use of the VFC-related fields varies by clinic; if you are unsure as to your clinic s use of these fields, as your nurse manager, or another individual in your clinic. 11. Select the appropriate number in the immunization series. (The Tdap is not usually given a second time; however, a second slot is available, to be used when the patient must in fact receive it more than once.) 12. Review any information displayed about prior, related immunizations recorded in the patient s chart in the display boxes on the right. Then, give the patient the VIS handout, go through the immunization-specific consent concerns, then click Consent Done. 13. Identify and click the appropriate Load button, which populates predefined fields with associated default values. 14. Type the lot number in the Lot # field. 15. Use the calendar utility or type directly into the Exp. Date field to document the expiration date. 16. Select the appropriate site from the dropdown options in the Site field. 17. Choose from the dropdown options of the Source field to document the source of the immunization serum. 18. Click in the appropriate option in the Type field. 1 VFC fields are not usually included on the forms of immunizations given to adults that are not covered by the VFC program. Prepared by Michigan State University EMR 4 of 17

7 19. If all fields have been completed as needed, including the Consent checkboxes, the form s Record button is activated. You or someone else in your clinic MUST click the Record button, or the information in the various data fields will not be saved. This it to help ensure that all fields have been filled in, and to trigger safety checks to run in the background. The Record button becomes active only values have been documented in all the required fields 20. (Optional) Enter additional information regarding the immunization administered in the Comments field. 21. (Optional, use if part of your clinic s protocols) Click the <Resp Prov button. 22. When the Record button is clicked, the Administered By field becomes populated with your name, the date, and time. If appropriate, modify the information there; otherwise, it can be left as is. 23. (Optional) Repeat the entire process to record additional immunizations administered during the current visit. Ending the Update When you have finished recording the immunizations given during the current visit, if there is no further information to add to the chart update, it is time to End the Update. The process of Ending an Update varies, depending on the individual clinic s document-signing protocols, and the signing privileges of the individual Ending the Update. The standard process is described below; however, if you are unsure about your clinic s protocols, please seek advice from your nurse manager, or someone else versed in the use of Centricity EMR in your area. 1. Click the Close button in the lower right corner of the immunization form to close that form and return to the textual portion of the chart update. 2. Check the text in the note to make sure that you have recorded the immunization(s) documented, then click the End Update icon, located on the right side of the Charting toolbar. 3. The End Update window opens. The Summary line should already reflect the nature of the update, but if it does not, it should be modified accordingly. This helps you and other HealthTeam Centricity users looking at the patient s list of documents to easily identify the various concerns and/or healthcare issues addressed in those documents. 4. Use the dropdown Provider list to locate and select the Provider who is responsible for the update, if it what already appears there is incorrect. Prepared by Michigan State University EMR 5 of 17

8 5. Depending on the circumstances of this particular chart update, in the Route To section, put a checkmark () in the appropriate checkboxes to have the chart update routed to the Desktop of the Provider identified, or another HealthTeam Centricity user. Check the content of the Summary and Provider fields for accuracy. When applicable, make sure that the document is set to be routed to the appropriate person(s). 6. If more information needs to be added to the update, or if someone else needs to sign it, click Hold Document. Click Cancel if you want to return to the note itself to either check on something entered there, or to make additional contributions. If you have the authority to Sign the document and no further changes are needed therein, click Sign Document. Prepared by Michigan State University EMR 6 of 17

9 AN IMMUNIZATION FORM EXAMINED The basic layout and functionality of forms used in HealthTeam clinics to record the details of various immunizations administered are the same, varying only as required for immunization-specific protocols. Having a good understanding of how these forms work helps HealthTeam clinicians and staff members in the documentation process. A Standard Immunization Template (shown here with the #1 Tdap immunization selected) Safety Point Many of the immunization forms used in HealthTeam clinics have age and series-interval checks built into them to help the clinician identify immunizations for which the patient is or is not eligible, per ACIP 2 recommendations. Nonetheless, the individual making immunization decisions in a HealthTeam clinic should not rely solely on these form functions; he or she should remain cognizant of the actual recommendations. 2 ACIP: Prepared by Michigan State University EMR 7 of 17

10 Name and Age Checks The patient s name, age and gender are displayed at the top of the form. Always make sure that the chart update is in the correct patient s chart before beginning the immunization documentation process. When applicable, an age check is run as a form is loaded into the chart update. If the patient does not meet the recommended age requirements, a note in bold textual alert appears in the form. Details of an immunization s age parameters are on the second tab of the form. VFC Eligibility The patient s Vaccine For Children (VFC) eligibility is displayed near the top of forms used for immunizations that are covered by the VFC program. Previous values entered in the patient s chart are displayed by default, and the person filling out the form for a new instance may leave the information as is, or update it as needed. Additionally, the individual may choose to include the VFC-related information in the textual portion of the chart update, or omit it. Place a checkmark here only if you want to include the VFC information in the text of the chart note Selecting the Correct Number in an Immunization Series Many of the immunizations routinely given in HealthTeam clinics are in series, with the timing between instances of doses administered very important. So, if the wrong number is chosen when documenting a particular number in the series, it can lead to not only incorrect documentation in the patient s electronic record, but also incorrect immunizations given to that patient hence the need to review the data displays in the various immunization forms. The illustration here shows a second dose of Tdap selected for recording, yet the patient as yet has no instances of an initial Tdap immunization. Extra Options Some forms include an extra slot for the recording of non-standard immunizations, as shown here with Tdap. Typically, patients receive a single dose of Tdap, but a second option is available, in case a patient must have the Tdap repeated. Other examples of when an additional dose of a particular immunization might be needed is if the patient did not meet the minimum age requirement when he or she received the first dose, or if too little time elapsed between doses in a series. Prepared by Michigan State University EMR 8 of 17

11 Selecting the Correct Number in an Immunization Series - Continued When a number in an immunization series is selected, fields are displayed in the middle of the form where the details of that immunization are to be documented. Tdap is typically given only once to a patient, so we will now look at some features included on the form of a multiple-dose immunization. Illustrated below we see the DTaP form, with slots for six doses available. The second tab of the form provides a detailed view of the DTaP and related immunizations, as well as standard protocols; we ll look at this second tab once we ve completed our examination of the form s first tab. Actual instances of DTAP would be displayed here Instances of related immunizations displayed here, and referenced in the display below The DTaP immunization is sometimes given alone, but is also frequently given as a part of a combination immunization; so, in the DTaP form there are two display areas that show both previously recorded DTaP immunizations and DTaP-related immunizations. Additionally, the illustration here shows that if the first dose in the series has been selected, and there already exists in the chart something that represents that first dose, a textual display alerts the user to that effect. When you see that there are related immunizations already in the patient s chart, use the second tab of that immunization form for a more detailed view of those immunizations. Alternatively, close the form, put the chart update On Hold, and check either the Immunizations Comprehensive handout or the All Immunizations flowsheet. Safety Point Many of the standard immunizations are given as part of combination immunizations, such as Pediarix, Pentacel, or Twinrix, so it is important to look not only for entries already on the patient s record of single immunizations, but also those related combination immunizations. Prepared by Michigan State University EMR 9 of 17

12 Selecting the Correct Number in an Immunization Series - Continued If a second dose is selected, yet there is no first dose for that immunization in the patient s chart, a textual display asks the user to verify that the correct number in the sequence has been selected. Illustrated here you see DTaP #2 selected, yet a note indicates that no DTAP #1 has been recorded. Similar notes are displayed for the other numbers in the series, as well. However, only a certain degree of cross-checking occurs in the system; ultimately, the person making immunization recommendations must also look for variations of the same immunization already given. Intervals Many of the multi-dose immunizations have strict requirements that mandate minimum intervals between doses. For example, no less than four weeks (28 days) must elapse between the second and third doses of DTaP. Several of such immunizations, though not all, have forms in Centricity EMR that help the clinician or staff member recognize when it is too soon to give an immunization to a HealthTeam patient. The illustration here shows the textual display that appears if the clinician or staff member selects a second instance of the Varicella immunization, but with too little time having elapsed since the administration of the first dose. Catch-Up Schedules Immunizations typically have two schedules, the first being the recommended age and/or interval sequencing, and the second being used for patients who have fallen behind on their immunization and need to get caught up. For the most part, the interval checks performed in HealthTeam immunization forms follow the standard recommended schedule and display textual alerts accordingly. If a patient falls under the catch-up category, the clinician should follow the alternative schedule, as provided by the State of Michigan, or online at Additionally, many of the immunization forms include catch-up recommendations on their second tab. The Catch-Up Schedule Displayed on an Immunization Form Prepared by Michigan State University EMR 10 of 17

13 Intervals - Continued A few of the multi-dose immunization forms used for recording newly administered immunizations in HealthTeam clinics include a function that calculates the due date of the next dose in a series. The illustration here shows the calculated due date of the second dose in series in which the first dose has just been recorded. The date displayed is the earliest date the immunization should be administered, per the standard schedule. NOTE: The next due calculations follow standard sequencing recommendations; they do no accurately reflect dates for catch-up schedules. Consent or Decline The next section of the immunization form addresses the consent/decline aspect of the administration of immunizations. If the patient or parent/caregiver agrees to the administration of the immunization, the individual filling out the form clicks the Consent Done button. This puts checkmarks () in each of the required Consent checkboxes. It also enters text into the chart note that indicates that the immunization s Vaccine Information Sheet (VIS) was given to the patient or parent/caregiver. VIS details displayed and entered in the chart note The various checkbox fields consist of: standard Consent questions immunization- and gender-specific concerns Consent Features Safety Point The Record button used to save the details of a newly administered immunization remains inactive until the clinician or staff member completing the form has checked each of the required Consent questions. This requirement helps guarantee that the consent process has been followed, therein protecting HealthTeam patients from immunization-related, undesirable side effects or consequences. Prepared by Michigan State University EMR 11 of 17

14 Consent or Decline - Continued Removing Consent If you click the Consent Done button either in error, or because the patient or parent/caregiver has decided against the immunization, remove the checkmarks from the Consent-related checkboxes. Not doing so inappropriately leaves the consent-related text in the chart update and, ultimately, in the signed document in the patient s record. Declines If the patient or parent/caregiver declines the recommended immunization, the clinician or staff member filling out the immunization form should click the Declines button on that form. When clicked, the declination is entered into the text of the chart update, and when that update is signed, it becomes a permanent part of the patient s record. The Decline statement in a chart note if the patient or the parent/caregiver declines the recommended immunization. Decline Checks If recording that the patient or parent/caregiver has declined an immunization, make sure that: The patient or parent/caregiver signs the Declines Immunization form provided by the clinic, and that document is then scanned into the patient s record. Any and all checkmarks () already entered in the immunization form have been removed You do not click the Declines button more than once, as doing so saves multiple entries of the information in the patient s record. If you click the Declines button when in fact the patient has consented to and received the recommended immunization, you or someone in your clinic must remove the declination statement entered in the patient s record, using the Update Flowsheet button, in the lower right corner of the form. If you do not, potentially conflicting information regarding the patient s consent/declination will be saved in the patient s record. NOTE: A patient or parent/caregiver declining a recommended immunization in a HealthTeam clinic is not the same as that individual declining the transmission of the immunization record to MCIR. If in fact the declination is for the sharing of immunization information with MCIR, a clinician or staff member must log into the MCIR website and document the declination there. Prepared by Michigan State University EMR 12 of 17

15 Details of the Immunization Administered To examine more of the details included on HealthTeam immunization forms, we ll now move to the form used to document the administration of the Hepatitis B immunization. This form varies from other immunization forms slightly, as it includes a field where an At Birth dose can be documented for historic purposes. Also, in the middle region of the form, there are buttons that allow the individual filling out the form to select from the four type/dose options available. The Hepatitis B Form The Hepatitis B At Birth Dose Typically, an infant receives his or her first dose of the Hepatitis B vaccine shortly after birth, usually in the hospital. To document that initial dose in the infant s Centricity chart, first make sure that the dose has not already been documented in the patient s chart; if it had been, it would be displayed in the Birth Dose display field. Having verified that it has not already been recorded, enter the date the immunization was administered in the Given field, then click the Record button. NOTE: The Hepatitis B at-birth dose should not be recorded in the patient s chart as the first in the 3-dose series; doing so makes it difficult for the clinician to determine how many additional doses the child should get, and the interval sequence. Prepared by Michigan State University EMR 13 of 17

16 Details of the Administered Immunization Continued When a number in a series is selected in the upper portion of the form, several of the fields related to that instance are displayed in the middle section of the form. Also, buttons are displayed that allow you to enter the default values of a given immunization into predetermined fields. Because the options for the Hepatitis B immunization require a good deal of space, they appear in the left-most column in the form s midsection. Most of the immunizations administered in HealthTeam clinics have fewer options, with shorter names, so they typically have Load buttons to the left of the immunization header, also in the form s midsection. Hepatitis B Load Buttons DTaP Load Button Tdap Load Buttons The illustrations above show three immunization forms Load buttons. The fields populated when one of these buttons is clicked, and the values entered in those fields, are determined by both the dose selected and patient s age. The illustrations below show the default values entered when the Load buttons indicated have been clicked in the chart of a patient under the age of 19, and the specific buttons clicked identified in the illustration. DTaP #1 Load Button Clicked Energix 10 mcg Button Clicked Load Adacel Button Clicked Safety Point Whenever appropriate, use a Load button to enter the details of an administered immunization, unless those details vary from the default values entered. This reduces data entry errors, which in turn improves the quality of the information in both the patient s HealthTeam chart and his or her MCIR record. The Record Button The information entered in the immunization form is not saved into the patient s chart until its Record button has been clicked. However, the Record button does not become active until each of the form s required fields have been filled in. Typically, this means that the Consent checkboxes and each of the fields in the form s midsection must be completed. Prepared by Michigan State University EMR 14 of 17

17 The Record Button - Continued Once the Record button becomes active, you should review the information you have entered into the various fields, then click that button. Doing so causes data checks to run in the background and, if one of those checks fails, a pop-up alerts you of a problem. The illustration here shows the data fields completed, but the date entered in the Expiration Date field has already passed. Expiration Date Check If a pop-up indicates that the expiration date entered has passed, click the OK button to close the pop-up, then make the necessary correction to the Expiration Date field. Having made the correction, click the Record button again. Comments A Comments field is available in the lower portion of the immunization form, where additional information regarding the administration of that particular immunization can be documented. An example of when this might be useful is if the patient has brought an immunization acquired at a pharmacy and is requesting help in its administration. Such might be the case if a female patient has gotten the HPV vaccine at a pharmacy and is at the clinic for any one of its three doses. Administered By When the Record button is clicked, the Administered By: field is populated with the name of the person who has clicked the button, along with the date and time. When applicable, an additional name can be entered there, as well. Prepared by Michigan State University EMR 15 of 17

18 The Update Flowsheet Button The Update Flowsheet button in the lower right corner of the immunization form allows you easy access to the flowsheet view of the chart update, where data recorded during the chart update can be both viewed and removed. While at times this is a useful and needed step to take to guarantee accurate documentation in the patient s record, it should only be used with caution, as other information recorded during the update could accidently be deleted. The Second Tab Most forms used to document immunizations administered in HealthTeam clinics include a second tab; this tab displays the following: A flowsheet view of related immunizations already recorded in the patient s chart. Immunization-specific recommendations. A catch-up schedule. An Update Flowsheet button. The Second Tab of the HPV Form Safety Point The tools on the second tab of immunization forms are intended to assist clinicians in determining immunization recommendations; they do not replace the need for clinicians to consider all factors that may impact those recommendations, including those that might not appear on the forms. Prepared by Michigan State University EMR 16 of 17

19 DOCUMENTING IMMUNIZATIONS IN BRIEF The intent of this section is to provide a set of instructions on the basic process of documenting an immunization administered in a HealthTeam clinic, without explanation of the variations and cross-checks. Please refer to the preceding sections of this document for more comprehensive coverage. Recording an Immunization Administered using a new Chart Update 1. Unless there is already a chart update in progress that includes the necessary immunization form, click the Update button to begin a chart update. 2. In the Update Chart window, select Immunizations from the list of Encounter Types available. 3. Still in the Update Chart window, select the appropriate name for Provider. 4. Click OK to close the Update Chart window. 5. Now in the Immunizations chart update, either the *Immunizations Menu - Pediatric or *Immunizations Menu Adult form opens. Using the example of an adult female who is receiving the first dose of the HPV immunization, click the HPV button to load it into the encounter. 6. Click the Next Form (Ctrl + PgDN) button to navigate to the HPV form. 7. Select the appropriate number in the immunization s series that the patient is to receive during the current visit. 8. Give the VIS to the patient, and click the Consent button. 9. Near the middle of the form, click the Load button associated with the first HPV dose; this fills in the Trade name, Manufacturer, Route, and Type fields. Verify that the data auto-populating these fields is correct, and make any necessary corrections. 10. Fill in the remaining fields in the form s midsection. 11. With the Consent process and requisite fields completed, click the Record button. 12. (Optional) Repeat the process to document additional immunizations administered during this visit. 13. Click the Close button to close the immunization form. 14. Click the End Update button on the Charting Toolbar. 15. Complete the End Update process per the circumstances of the note (i.e. Is it really done, or does it require further attention?) and your clinic s signing and routing protocols (i.e. Are you the person responsible for signing the document, or does a different clinician in your clinic need to sign it?). Prepared by Michigan State University EMR 17 of 17