Mdh Pediatric Immunization Record Form PDF Details

The MDH Pediatric Immunization Record form serves as a comprehensive tool for healthcare providers, enabling them to meticulously document vaccinations administered to children. It includes essential details such as clinic name and address, patient information—last name, first name, middle initial, gender, date of birth, and mother's maiden name, serving as a cornerstone for tracking immunizations in alignment with federal law requirements. The form is designed to ensure that healthcare providers give the Vaccine Information Statement (VIS) to the vaccine recipient, parent, or authorized representative, as it's required for each routinely recommended vaccine. It comprehensively covers vaccine types, dates administered, manufacturer codes, lot numbers, routes, sites, dosages, and signatures of the vaccine administrators. Furthermore, it addresses special cases like recording combination vaccines, instructions for documenting vaccine reactions, transferring immunization details from other clinics, and utilizing the Minnesota Immunization Information Connection (MIIC) for maintaining up-to-date immunization records. By including manufacturer codes and details on how to record injection routes and sites, the form facilitates precise vaccine documentation, highlighting its pivotal role in safeguarding children's health through immunization.

QuestionAnswer
Form NameMdh Pediatric Immunization Record Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesvaccinee, CSL, IMITNID, Hx

Form Preview Example

 

 

 

PEDIATRIC IMMUNIZATION RECORD

 

 

 

Clinic name and address:

 

1 This information is required by federal law.

 

 

 

 

 

 

 

 

 

 

 

Last name:

 

 

First:

 

M.I.:

Gender:

 

 

 

2 Give Vaccine Information Statement (VIS) to

 

 

 

 

 

 

 

vaccinee, parent, or authorized representative

 

Date of birth: ____/____/______

Mother’s maiden name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for each routinely recommended vaccine.

Vaccine

Type of vaccine

 

Date given1

 

Mftr1

Lot#1

Route

 

Site

 

Dosage

Signature and title of vaccine administrator1

Date on bottom

Date VIS given to

Hx of vaccine

Given elsewhere

 

MO/DAY/YR

 

(see back)

 

RA/LA/LT/RT

 

of VIS1

patient1,2

reaction (ü)

(ü)

 

 

 

 

 

 

 

 

 

 

 

Diphtheria, Tetanus,

 

1

 

 

 

 

IM

 

 

 

 

 

 

 

 

 

Pertussis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Polio

 

1

 

 

 

 

IM ● SC

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

IM ● SC

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

IM ● SC

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

IM ● SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ● SC

 

 

 

 

 

 

 

 

 

Measles, Mumps, Rubella

 

1

 

 

 

 

SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Haemophilus

 

1

 

 

 

 

IM

 

 

 

 

 

 

 

 

 

inluenzae type B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Hepatitis A

 

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IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Hepatitis B

 

1

 

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Human Papillomavirus

 

1

 

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varicella

 

1

 

 

 

 

SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal

 

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IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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IM ● SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ● SC

 

 

 

 

 

 

 

 

 

Inluenza

 

 

 

 

 

 

IM●ITN●ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IM●ITN●ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IM●ITN●ID

 

 

 

 

 

 

 

 

 

Meningococcal

 

1

 

 

 

 

IM ● SC

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

IM ● SC

 

 

 

 

 

 

 

 

 

Rotavirus

 

1

 

 

 

 

PO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Minnesota Immunization Program: 651-201-5503 or 1-800-657-3970

www.health.state.mn.us/immunize

IC#140-0498 (03/13)

How to use MDH’s Pediatric Immunization Record form

Make this record easily accessible

Keep each patient’s immunization record where you can easily review it during each ofice visit (e.g., the front inside cover of the patient’s medical

chart).

Patient behind schedule?

Flag the record if the patient is behind on recommended immunizations.

Record type of vaccine

Be sure to indicate the type of vaccine you gave. This is especially important when you give DT-pediatric rather than DTaP since children who receive DT-pediatric will be at higher risk of pertussis disease if there is a pertussis outbreak in the community.

What information is required by federal law?

You are required by federal law to record the following information as part of the National Childhood Vaccine Injury Act:

•Manufacturer and lot number of vaccine given.

•Date vaccine given.

•Date of publication of the Vaccine Information Statement (VIS) and the date the VIS was given to the vaccinee (or parent or legal representative of the minor child).

•Name, title, and address of the person who administered the vaccine.

Note: Federal and Minnesota laws do not require written informed consent. However, some clinics may have their own policy.

How to record combination vaccines

Record a combination vaccine under each speciic antigen that the vaccine contains. Use a hyphen between each antigen. Examples:

Hx of vaccine reaction (history of vaccine reaction)

If the patient has experienced a clinically signiicant or unexpected event after an immunization (even if there is uncertainty that the vaccine caused

the event), place a ü in the “Hx of vaccine reaction” column. Provide more speciics about that event elsewhere in the patient’s chart. Report vaccine

reactions to the Vaccine Adverse Events Reporting System (http://vaers.hhs.gov/index or 800-822-7967).

Transferring immunization information onto this form

Transfer vaccine information that patients receive at other clinics to this record. If you don’t know all of the information, record at least the date (mo/ day/yr) and type of vaccine. The responsibility for maintaining the federally required information is with the clinic that administered the vaccine. Be sure to place a ü in the “Given elsewhere” column. If a patient transfers to another clinic, provide a photocopy to the new clinic.

Use the MIIC registry to record and ind immunizations

If you’re participating in the Minnesota Immunization Information Connection (MIIC), be sure to enter or submit data on new shots for this patient so it is available to others who may be giving subsequent doses. MIIC is located at https://miic.health.state.mn.us. If you are not yet participating, call

800-657-3970, or visit www.health.state.mn.us/immunize (click on “MIIC

Registry”) to ind out how to enroll.

Manufacturers’ codes

Use the codes listed in the chart below to indicate the manufacturer of the vaccine. These are the same codes used universally and by the Minnesota Immunization Information Connection (MIIC).

•TriHibit is DTaP-Hib. Record it under both DTaP and Hib.

•Comvax is Hep B-Hib. Record it under both Hepatitis B and Hib.

•Pediarix is DTaP-IPV-Hep B. Record it under DTaP, IPV, and Hepatitis B.

How to record injection routes and sites

The most common routes for vaccination are intramuscular (IM) and subcutaneous (SC or SQ). Less frequent routes include oral (PO) and intranasal (ITN). If there is more than one choice for route, circle the route

Vaccine Manufacturer

Code

CSL Biotherapies

CSL

 

 

GlaxoSmithKline

SKB

 

 

ID Biomedical

IDB

 

 

Massachusetts Biologic Labs

MBL

 

 

MedImmune, Inc.

MED

Vaccine Manufacturer

Code

Merck & Co., Inc.

MSD

 

 

Novartis

NOV

 

 

Pizer

PFR

sanoi pasteur Inc.

PMC

Wyeth Vaccines

WAL

given. Sites for injections should be noted as to which limb and what side. These include right thigh (RT), left thigh (LT), right arm (RA), and left arm (LA).

Immunization Program P.O. Box 64975

St. Paul, MN 55164-0975

651-201-5503 or 1-800-657-3970 www.health.state.mn.us/immunize

Your patients need personal immunization record cards

Always update the patient’s personal immunization record with information on the vaccines that you administered. If your clinic needs personal immunization record cards, order the MDH Gold Card by calling 800-657-

3970, or 651-201-5503, or by illing out the order form at www.health.state.

mn.us/immunize.

How to Edit Mdh Pediatric Immunization Record Form Online for Free

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vaccinee writing process shown (step 1)

2. Once the last section is completed, go on to type in the applicable details in these - Human Papillomavirus, Varicella, Pneumococcal, Inluenza, Meningococcal, Rotavirus, IM SC, IM SC, IMITNID, IMITNID, IMITNID, IM SC, IM SC, Minnesota Immunization Program or, and wwwhealthstatemnusimmunize.

vaccinee writing process detailed (step 2)

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