Documentation record keeping A Must Dr Chetan Trivedi

Documentation & record keeping – A Must! Dr Chetan Trivedi M. D. ; D. Ped Practicing Pediatrician & Neonatologist Neha Children hospital Kankaria, Ahmedabad Ex Hon Asst Professor & Infectious Disease Consultant U N Mehta Institute of Cardiology & Research Centre Past President , Academy Of Pediatrics, Ahmedabad- 2013 -2014 Executive Board Member, Gujarat, CIAP 2016

Outline • What to document? • What is must to document? • What is best practice guideline for documentation? • Why to document? • What if not documented? • What is the way out when not documented?

Uniform documentation Vaccinee Documentation Vaccination AEFI

Documentation of Vaccinee Name Age /DOB Weight Birth Weight / maturity at birth Maternal HBs. Ag Status

Documentation of vaccine Name – Generic & Brand name volume Disease against which protection Manufacturer Lot number , batch number & date of Expiry Combination

Best Option-Adhesive labels • Rotaviral vaccine monovalent or pentavalent or 116 E : Number of doses differ • Hep A Vaccine : Live / Inactivated: Number of doses differ

Documentation of Vaccination Site of vaccination • Immunization site map Date & Time of vaccination • Next date of vaccination Name of vaccinator or vaccine provider • With signature if possible Plan of vaccination schedule( If customized) • e. g. 2+1 , 0, 1, 6 etc

Immunization site map

Where to document? Immunization card / chart Prescription paper In computer as soft copy

How to find out undocumented vaccine types? By site By route By cost By reactogenicity By diseases By number of vaccines • Left or Rt shoulder • Thighs or para umbillicus • Oral / Injectable • Intranasal • Amount charged in Private setup • Fever , pain at site or swelling • For which diseases : Measles , chickenpox etc • One in arm + one on thigh + oral etc

Documentation of AEFI • Experience of AEFI by you or History of AEFI • Anaphylaxis • Excessive crying (Persistent inconsolable cry for >3 hours duration ) • Fever - hyperpyrexia (fever >40. 5 C) • Hypo responsive episodes HHE • Swelling at Injection site • Seizure with or without fever

What WHO International certificate of vaccination says? Target Disease Name & Brand of vaccine Manufacturer Batch Number Surprisingly Not the date of expiry!

Best practice guidelines for documentation What is best? . Document maximum possible details clearly on the card or paper

Immunization card for record- a must • On File / Separate paper • In English as well as vernacular language • Enough space for details

Ideal immunization card Name : Age of vaccine Type/ To be vaccina brand given tion of date vaccine Date of Birth : Give n date Sit e Vaccine Lot no Label / Date of Mfr Expiry Vaccinator name & Sign

Documentation with respect to specific vaccine: • BCG • On follow up visit at 6 weeks check for the BCG scar & mention it for self audit & Documentation. • Rabies: • Categorization of bite • Name of animal • Provoked or unprovoked • Wound cleaned immediately or not • Mention day of bite & vaccination date with details of Rabies vaccine & or RIG.

Consent ? • Written consent not needed • Implied consent

Documentation of “Decision not to vaccinate” • AAP website form : • Parents decide not to vaccinate even after explaining for it. • Exemption to vaccination : • Medical contraindication or natural immunity

Documentation of self vaccination & staff’s vaccination record get o t t e g r o f Don’t urself & o y d e t a n i vacc ur staff o y e t a n i c to vac too!

Documentation & Report submission to Municipal Corporation or Health Authorities: • Report vaccination doses to reliably estimate vaccination coverage; • AEFI to identify and monitor vaccine safety; • Notifiable vaccine-preventable diseases, to monitor the impact of vaccination

Advantages of Documentation Ease of vaccine choice & vaccination Avoid unnecessary vaccination Reduction of missed opportunities to provide vaccination Saves time for vaccination Facilitates use of vaccine reminder & recall notification to patients • Ease of providing record for visa or immigration purpose • Data collection & easy calculation of your immunization coverage rates • Medico legal help in case of AEFI • • •

Summary • Documentation of vaccination is a must! • Document all details about vaccinee , vaccination & AEFI clearly. • Document Immunization at office based card as well as home based cards. • Documentation helps for smooth , safe & error free vaccination.