Immunization Documentation

The Connect Care health record supports documentation of a patient's immunization history. Documentation of immunizations is integrated with immunization ordering and administering where Connect Care is the record of care. Obviously, patients may have been immunized in settings using other information systems, in private travel clinics, in community physician offices or in jurisdictions outside of Alberta. Connect Care immunization documentation tools support composition of a comprehensive immunization history using information gathered from different sources in different ways:

  • Connect Care Orders and Documentation
    Any vaccination ordered in Connect Care is automatically tracked in Connect Care and Connect Care supports prescriber-entry of historical vaccination information.

  • Provincial Immunization Records
    Immunization data for provincially funded, public health clinic, and some privately funded immunization services are recorded in a provincial immunization repository, currently outside of Connect Care. An interface to the Alberta Netcare Portal available provincial immunization records in Netcare and some Netcare immunization information may be exchanged with Connect Care at intervals.

  • Legacy Clinical Information Systems
    Immunization information is included in data conversion protocols that bring health data from legacy clinical information systems into Connect Care (e.g., eCLINICIAN, Meditech) and other systems (e.g., Sunrise Clinical Manager) can be checked from within Connect Care.

  • Electronic Medical Records
    Work is underway to improve capture of summary information from community electronic medical records to Netcare and Connect Care via a "continuity of care" interface.

  • MyAHS Connect Patient Portal
    Patients can submit suggestions for chart additions, including missing immunizations.

Immunization information, like medication and allergy information, needs to be checked so that missing information can be added and incomplete information updated. An immunization documentation activity allows Connect Care providers to ensure that important immunizations are documented in a patient's record of care.

This section highlights how immunization information can be reviewed and revised using Connect Care documentation tools.

Finding Immunization Information

The "Chart Review" activity is available in all Connect Care charts, irrespective of the context or encounter that they may be opened to. Within Chart Review, the "Patient SnapShot" shows as the default (first) tab. This includes an "Immunizations/Injections" section listing immunizations known to Connect Care. Selecting the link in the section header will open an "Immunizations" activity that shows more details.

The "Immunizations" activity can also be opened via Chart Search by searching for "Imm" then "Jump to Immunizations".

Self-reported Immunization Information

Patients may be able to self-report their immunization status for some conditions. This can be done directly using MyAHS Connect (patient portal) questionnaires or communications. Self-reporting may be indirect when incorporated into provider-administered screening at transitions of care, as applies to self-reports of COVID-19 vaccinations.

When patient-reported information is at odds with Netcare or Connect Care records, formal immunization records should be requested and evaluated via a provincial validation process. Any unvalidated self-reported vaccination status should be considered informational only, not to be entered to the Connect Care immunization history until confirmed through an approved evaluation of formal records.

In the case of COVID-19 vaccination self-reports, the following categories and definitions are used:

  • None - The patient has not received any dose of an approved COVID-19 vaccine, or is within 14 days of receiving a first dose.

  • Partial - At least 14 days have passed since receiving a first dose of an approved COVID-19 vaccine but the patient is within 14 days of completing a full series according to the vaccine requirements from the manufacturer.

  • Full - At least 14 days have passed since the patient has received a full set of an approved COVID-19 vaccination series. A complete series can range from one (e.g., Johnson & Johnson vaccine) to two or more doses (e.g., where a booster is required for a particular vaccine type or patient risk profile).

Adding to the Immunization Record

If missing immunization information needs to be entered into Connect Care, the "Immunizations" activity is used. This may also be needed if an interface between ordering and recording is not yet implemented (e.g., COVID-19 immunizations until order build is complete).

Be sure to work from official documentation of a vaccination event (a patient's verbal report is not sufficient).

Use the "Historical Admins" drop-down menu in the "Immunizations" activity title bar, as illustrated in a tip sheet:

Pulling Immunization Information into Clinical Documentation

One or more SmartLinks can be used to pull immunization data into progress notes and summative documentation objects.