Question Documentation Question

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We have been giving the Covid vaccines at our clinic and I have been going to the patients immunization record to determine which shot was given. I was told today that this information is incorrect and I need to look up the patients consent form to verify whether it is the 1st, 2nd or 3rd shot. Do I start doing this going forward or should I expect the IMM record to be correct? Please provide guidance.
 

thomas7331

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We have been giving the Covid vaccines at our clinic and I have been going to the patients immunization record to determine which shot was given. I was told today that this information is incorrect and I need to look up the patients consent form to verify whether it is the 1st, 2nd or 3rd shot. Do I start doing this going forward or should I expect the IMM record to be correct? Please provide guidance.
I think you need to ask the person who told you this for clarification - there could be a reason for this. Perhaps they are using the consent form because the patient may have received the previous doses from a different clinic and immunization record may not always include that information?
 
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If that is true, should they be documenting the previous doses? I guess I was under the impression that a patients shot record should be correct regardless of where a vaccination occurred, or is that only on a "paper" record?
 

thomas7331

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If that is true, should they be documenting the previous doses? I guess I was under the impression that a patients shot record should be correct regardless of where a vaccination occurred, or is that only on a "paper" record?
I'm not sure what you're asking - should who be documenting previous doses where?

Your patient's record of course should be accurate as to what was done in your own clinic, but if you're talking about the vaccination record that the patient is given that they carry with them, I'm not sure you can rely on that. A patient could have lost their original and started a new one that doesn't contain the record of every dose. But if you have an actual medical record from another clinic, I would think that would be reliable information. That's why I'm saying you should get guidance from the person who's giving you these instructions and can advise you on what you're looking at and why they want you to use one source vs. another. It's hard to say what's right or wrong without knowing exactly what your clinic is doing.
 
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