How to enter an Immunization | Scribe

How to enter an Immunization

    1
    Click on the Vaccinations Icon
    2
    Choose from the appropriate Vaccination card (Adult or Pediatrics) the immunization(s) you will be administering. Choose SP if giving the immunization as POC
    3
    From the resulting window, choose the Vaccine Type you will be administering.
    4
    Once chosen, some information may default, such as the current "Admin date, Dose, Units, Route etc. Other information should be filled in as applicable, Click on the > at the bottom of the screen to see other fields.
    5
    Ensure each field is filled in. Required fields are in yellow and need to be filled in so the information will go to the state registry without errors. Required fields are Completion Status, Dose, Units, Funding Source, Route, Site, Lot#, Manufacturer, Expiration Date. Use the Magnifying glass to choose from approved pick lists.
    6
    Example of pick list for Site administered.
    7
    Fields for Lot# is a free text field in order to record appropriate Lot# from packaging.
    8
    Exp. Date can be filled in by free typing or using magnifying glass to use calendar.
    9
    Free text in Administered By, and free text in VIS Given dates.
    10
    Click here: SP tab
    11
    Note that the Vaccine that has been entered previously has been added to the SP tab automatically by documentation in previous steps. Click here: on the Adult Vaccines or on Peds Vaccines to search for Admin code.
    12
    Click here: 90471 to add Vaccine Admin code. If giving multiple vaccines, click also 90472 for each additional vaccine given
    13
    If the patient is here for Vaccines only, click on the DX tab to add the Z23 code for Encounter for Vaccines.
    14
    Click on applicable Adult top 50 or Peds top 50 and choose the "Z23-V03.89 Encounter for immunization" to the DX, this will populate over to the SP tab. Continue entering and documenting the rest of your visit and when completed click on OK to close the note.