Patient Documentation

To encourage efficiency with the screening and documentation forms required prior to administration of an immunization, print and assemble packets beforehand. When a patient presents to the pharmacy for an immunization, a clipboard and pen should be provided with the:
Screening/consent form
Vaccine Information Statement (VIS)
Notification of Vaccination Letter
Any other documents required by the state Board of Pharmacy or your protocol physician
Depending on state-specific laws and regulations, the pharmacist may have to notify two physicians after administering an immunization. If required by your state or by the protocol physician, the protocol physician who signed the standing order should be notified of each vaccine administered under the standing order within the state-specific time frame. The patient’s primary care provider, if they have one, should also be notified of administration of the vaccine within the state-specific time frame if that is required.
The “Notification of Vaccination Letter” within this toolkit provides an example of a document that can be customized to meet your state’s requirements and used to notify the patient’s primary care provider of administration of the vaccine. This document can be faxed, emailed (if allowed), or mailed as long as it reaches the primary care provider within the state-specific time frame. It is recommended to fax the notification of vaccination immediately after administration of the immunization rather than waiting. Depending on state-specific laws and regulations, administration of an immunization may be required to be reported to the state immunization registry. If this is a requirement, contact your state Board of Pharmacy or immunization registry for information about the reporting requirements, as well as how to document and submit administration of an immunization.
Disclaimer
The materials provided are for informational purposes only and do not constitute legal advice. If you need legal advice, contact your attorney. The requirements established by the state in which the practice will occur may impose additional, fewer, or different requirements from those discussed in this section. The Toolkit is one resource to assist 
in starting up a pharmacy-based immunization practice, and the pharmacist is responsible for confirming and ensuring that the immunization practice complies with all applicable laws and regulations. In addition, the materials are not advice regarding how to practice pharmacy. Pharmacists are always required to use their own professional judgment.
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