Core Topic 11 Documentation, record keeping and reporting

Learning outcome Change the way you think about Hull | 7 October 2009 | 2 To correctly document vaccinations given in all relevant records, to communicate information to appropriate stakeholders

Learning Objectives Change the way you think about Hull | 7 October 2009 | 3 Document a vaccination correctly in all relevant records Explain the importance and purposes of recording information about vaccinations in each system Describe the role and importance of vaccination coverage data Describe the role of the Child Health System in record- keeping, calling and re-calling for immunisation. Report Serious Untoward Events

Record Keeping Change the way you think about Hull | 7 October 2009 | 4 Registered nurses have a professional and legal duty of care to their patients (NMC, 2015) Remember! Anything written in your capacity as a nurse could potentially be used in a court of law Accurate accessible vaccination records are important:  To help to protect you and the welfare of your patient  Assist in monitoring immunisation uptake  Facilitate recall of vaccine recipient if required

What needs to be documented? Change the way you think about Hull | 7 October 2009 | 5 When a vaccine is administered, the following information should be accurately recorded Name of vaccine Product name Expiry date - recording this is evidence that it has been checked Batch number - in case of future problems/recall Date vaccine is given Site of injection - including description of which injection was administered in each site Anterolateral aspect of the thigh or Deltoid area of upper arm, state left or right When 2 or more injections need to be given at the same time, they should preferably be given at separate sites in different limbs The name and signature of vaccinator

Where should it be recorded? Change the way you think about Hull | 7 October 2009 | 6 Personal Child Health Record (PCHR) or “Red Book” Patients/parents should be encouraged to look after their own vaccination records or that of their child’s. Can be a useful source of reference for other health care professionals who may be involved in episode of care eg:Accident & Emergency visits

Medical/GP records Change the way you think about Hull | 7 October 2009 | 7 This should contain details of all care given/received in primary care. Important as parent/patient may consult their GP in the hours or days subsequent to vaccination May need to ascertain individual vaccine status at a later stage

Child Health Information Systems (CHIS) Change the way you think about Hull | 7 October 2009 | 8 System automatically generates vaccination schedule for child and sends appointments Produces default list for missed appointments Maintains a comprehensive record of children in the area Allows the production of vaccine coverage data (COVER)

What is the COVER programme? Change the way you think about Hull | 7 October 2009 | 9 Cover of Vaccination Evaluated Rapidly (COVER) National programme for the collection of immunisation uptake (coverage) statistics from CHISs Crucial component in the surveillance of vaccine preventable diseases and informing Public Health Policy Monitors childhood vaccination uptake at local (provider service, CCG, StHA), regional and national levels Quarterly reports produced for percentage of children aged 1, 2 and 5 years completing routine scheduled childhood immunisations in that quarter Does not include adult vaccination programmes e.g. influenza

How it works Change the way you think about Hull | 7 October 2009 | 10 Child entered on Child Health Information System at birth System automatically generates vaccination schedule for child and sends appointments When child vaccinated practice/clinic sends return to CHIS and data entered on system In theory, system keeps up to date log of child’s immunisation status.

How it works cont… Change the way you think about Hull | 7 October 2009 | 11 At any time, system able to calculate what percentage of children in an age cohort/time period have received a particular childhood vaccine. Most CHIS also keeps records of vaccines given at school but these are not (yet) part of COVER programme as completeness of data on system decreases for older children

Objectives of the COVER programme Change the way you think about Hull | 7 October 2009 | 12 Improve vaccination coverage by regular accurate feedback to Provider Service Immunisation Leads Investigate reasons for poor performance Detects changes in uptake rapidly to allow early intervention Monitors response to interventions and changes in policy Stimulate local interest Investigate reasons for poor performance

Reporting adverse reactions Change the way you think about Hull | 7 October 2009 | 13 Suspected adverse drug reactions (ADRs) to vaccines should be reported to the Committee on Safety of Medicines using the Yellow Card Scheme: -For established vaccines, only serious ADRs should be reported -For newly licensed vaccines labelled with an inverted black triangle ( ▼ ), serious and non-serious reactions should be reported -All suspected ADRs occurring in children should be reported

Change the way you think about Hull | 7 October 2009 | 14

Links to Further Information Change the way you think about Hull | 7 October 2009 | Guidelines for records and record keeping: online/ (section 10) online/ 2. COVER information

Change the way you think about Hull | 7 October 2009 | 16 Minimum slide set created by: Immunisation Department, Centre for Infections, Health Protection Agency to assist teaching of the Core Curriculum for Immunisation Training lications/InfectiousDiseases/Immunisation/0506CoreCurriculumforImmunisationTrainin g/ lications/InfectiousDiseases/Immunisation/0506CoreCurriculumforImmunisationTrainin g/ And amended by Lizzie Ette, lecturer in nursing, January 2015

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