PDF on documenting immunizations:

https://www29.pointclickcare.com/help/online/en/SNF/en/documenting-immunizations.html

Documenting Immunizations

You can document immunizations in a resident's chart that are given at your facility or other clinics to maintain an up to date immunization record for the resident. This helps track when immunizations are due to ensure the resident does not miss or receive unnecessary immunizations. After entering the immunization in the resident's chart, the information can flow to reports and assessments.

Procedure

  1. Clinical >Resident > Immun.
  2. Click New. 
  3. Complete the fields as required.
  4. Click Save

 

Below is a list of the options available to you.

Note

Influenza and Pneumococcal vaccinations are reflected in the Look Back in Section O of the MDS 3.0. Pneumococcal vaccinations also populate as Yes for Consented and administered, or Historical. If Refused or Not Eligible is selected, Section O is populated with No and the reason.

  • Immunization - Select immunization.
  • Given - Select one of the following options.
    1. TBD - To be determined (TBD) shows the immunization as Consent Required in the immunization listing.
    2. Consented - Consent is received and verified.
    3. Refused - Shows the immunization was refused. Select a reason.
    4. Historical - Complete the fields to show as Historical in the immunization listing.
    5. Not Eligible - Shows the resident is not eligible for the immunization. Select a reason.
  • CVX Code - If enabled, you are required to select. 
  • Consent Confirmed By - Auto-populates that consent is verified or is disabled based on option selected for Given.
  • Consent Confirmed Date - Auto-populates with the current date or is disabled based on the option selected for Given.
  • Education Provided to Resident/Family - Select option, if applicable.
    1. Date Education Provided - Select date.
    2. Education Provided By - Type the name of the person that provided the education.
  • Date and Time of Administration - Type or select the date and time.
  • Route of Administration - Select option.
  • Amount Administered - Type information and select the measurement.
  • Location Given - Select option.
  • Manufacturer'e Name - Type information.
  • Substance Expiration Date - Type or select date.
  • Lot Number - Type information.
  • Administered By - Click the magnifying glass and select user.
  • Notes - Type information. 

Hints and tips

  • If the Consent Status appears purple, review and complete the next required step to complete the documentation process.
  • The immunization listing shows the most recent immunizations. Click the + next to the immunization to view previous entries.