Page 20 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

 The date the Vaccine Information Sheet (VIS) was given

and the publication date of the VIS, which appears on

the bottom of the sheet

 Written parental or patient consent (or refusal) to

vaccinate, after receiving and reviewing a copy of the

most current VIS available for that vaccine

 All injections, including dosage, site, route, manufacturer, lot

number, date and the name of the person administering

 All telephone communication, including evening and
weekend phone calls received after business hours

 All prescriptions (print or type to ensure legibility)

 Only approved abbreviations; the use of abbreviations can be

frequently misinterpreted and may result in harm to patients.
A list of accepted abbreviations and correct dose

designations is available on the Institute for Safe Medication

1
Practices (ISMP) website.
 Use of the metric system for medications

The Objective is to be Objective

What you document in the medical record should be first and
foremost objective. Any subsequent provider or third party

(insurance payer, accreditation agency, attorney or juror) should

be able to clearly recognize elements of the medical record

identifying individual care. The best way to evidence individual

1 www.ismp.org/tools/errorproneabbreviations.pdf

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