Your concern is shared. Documenting any injection, or vaccination, is very important.
There are multiple ways injections and/or vaccinations may be given, including but not limited to; intramuscular (IM), subcutaneous (SQ), etc.
Also, there are multiple manufacturers and brands of vaccinations. There are multiple ways vaccination may be purchased, e.g., single dose vial, single dose injection, multiple dose vial, etc. For each of these differences, there is a unique National Drug Code (NDC) number. In addition, there is a lot number on each vial or single dose injection (with needle attached).
CDC has some standards I believe will help support your request for more appropriate documentation. The website address is:
It is recommended that whoever is performing the vaccination document the vaccination given, the route given(IM, SQ, etc.), and the lot number, as well as their complete signature along with credentials. Initials are ok if ancillary staff are documenting on a flow sheet, but for an actual chart note the legible identity and credentials are to be written.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join