Standards for Practice: Vaccine Documentation

Keep an up-to-date record of the vaccines your patients have received to make sure they have the best protection against vaccine-preventable diseases.

To ensure patients get the vaccines they need and to prevent unnecessary vaccination, you should:

• Record vaccination in patients’ medical records
• Provide documentation of vaccines received to patients for their personal records.
• Document vaccinations in immunization information systems (IIS)

Immunization Information Systems (IIS)

IIS are confidential, community-wide, computerized databases that record vaccines administered by participating healthcare professionals.

Documenting vaccines into IIS can benefit your practice by:

• Consolidating vaccination records for your patients
• Helping you assess your patients’ immunization status
• Reducing chances for unnecessary doses of vaccine or missed opportunities to provide vaccines
• Facilitating use of reminder and recall notifications to send to patients
• Making calculation of your office’s immunization coverage rates easier

Learn more about Immunization Information Systems (IIS) or reach out to your state’s main contact regarding questions about your state or local registry.

Resources

• Adult Vaccinations: Team-Based Immunization (American Medical Association)
• Factsheet on Vaccine Documentation [2 pages]
• Sample vaccine administration record [4 pages]