Add an Immunization Entry for a Patient

If a particular procedure was not configured at the time of charge entry, or if you need to enter an Immunization entry without adding a charge, you can add it manually in the Immunization tab of the Clinical screen. Use the following steps to manually add Immunization information for a patient.
 

1. In Practice Manager, click the Clinical tab.
    

2. Enter or search for the patient's Account # for whom you would like to add an Immunization record.
    

3. Click the Immunizations tab.
    

4. Click the New button.
    

5. In the Immunization Entry dialog, enter or search for the Immunization Procedure.
    

6. Check the Service Date option, and then enter or select the date of service for the immunization record.
    

7. In the Manufacturers and Lot Numbers for this Procedure section, you have the ability to select applicable Lot and Manufacturer information that was entered previously for this immunization procedure and have that information populate the corresponding fields in the Immunization section below allowing you to enter this data more efficiently and effectively when this immunization is administered. To do this, highlight the applicable Manufacturer and Lot Number entry in this section, and that information will default into the corresponding fields in the Immunization section below.
    

8. In the Vaccination Information Statement section, you have the ability to select and configure Groups, VIS Documents, and Presented dates for applicable vaccine procedures. Multiple documents and dates can be configured when applicable. To add a group, click the adjacent checkbox next to the applicable group Name. You can then select the appropriate VIS Document, and modify the Presented date by clicking into the date field and then selecting the correct date as needed.
    

9. Enter or search for the Provider associated with this immunization.
    

10. Enter, modify, or search for the Manufacturer you want to attach to the immunization record. This field is required for NJIIS and NYSIIS.
     

11. Enter or modify the Lot Number you want to attach to the immunization record. This field is required for NYSIIS.
     

12. Check the Lot Expiration option and then enter or select the Expiration Date for the Lot Number, if applicable.
     

13. Enter or search for the VFC Eligibility Code you want to attach to the immunization record, if applicable.
     

14. Select the applicable NDC Code for this immunization in the corresponding field, if needed.
    
    NOTE: The NDC field drop-down will contain any NDC codes that were configured in the procedure file. When entering a new immunization entry in the Immunization tab of the Clinical screen, the NDC code that was tagged as the primary in the procedure file will default into the NDC Code field. If the immunization procedure was entered as a charge in the Charge screen, the NDC Code field will contain the NDC code selected there and you can modify this field as needed. Primary NDC codes will be designated with a (P) after the code.
     

15. Enter or search for the CVX Code you want to attach to the immunization record, if applicable. The CVX code will default from the procedure file.    
     

16. Select the Funding for this immunization, if applicable. This field will default the funding option configured when adding immunization information for the procedure.
     

17. Check the Disease Immunity option when a patient cannot receive a vaccination because they have already been exposed to the disease. For example, a child who has had the chicken pox cannot be subsequently vaccinated against the chicken pox.
     

18. Check the Historical option to indicate that the office did not administer the immunization and it is being entered as a historical immunization for the patient. Likewise, when information is sent to NYSIIS, an immunization procedure that is tagged as Historical will have a registry status of 01; if this box is left unchecked then the registry status will appear as 00.
    
    When the Historical option is checked, in the Source field you can select the applicable Immunization Information Source. This information is required for Meaningful Use Stage 2.
     

19. Enter or search for the Dose, Route, Site information for the immunization in the corresponding fields.
     

20. Enter or search for the Administered By for the immunization. Do note, when entering a new immunization, this field will default to the current user.
     

21. Enter or search for the Facility in which the immunization was administered.
     

22. In the Immunization Consent section, enter the First Name, Last Name, and Consent Date, select the Relationship, and check the Consent for Immunization and Permission to Share options if applicable.
    
    NOTE: The Consent for Immunization and Permission to Share options are not used when sending immunization information to registries via the HL7 2.5.1 format. Consent for sending immunization information to registries in the HL7 2.5.1 format is entered via the Consent dialog accessed via the Patient screen in Practice Manager, or the ID tab in Clinical. However, the Consent for Immunization option should still be configured at the procedure level (in the Order Procedure dialog in Clinical, and/or the Immunization Entry dialog in Practice Manager) to provide accurate documentation within the chart note and patient's record, when applicable.  

     

23. When finished adding the Immunization information, click the Save button.
     

24. Click the Next Account button when finished.
     

25. Once the Next Account button has been clicked, the immunization information will be sent to those registries (DelVAX and PASIIS) that are configured for bidirectional exchange. For those registries that do not support bidirectional exchange (MD IMMUNET, NJIIS, NYSIIS, KIDS, and VIIS) you must manually create and send a file to those registries. See the individual registry instructions for specific details.