10845
Increasing the Reliability of Vaccine Records on Infants
During a review of immunization records it was noted that the Hepatitis B #1 was not always being entered into the EHR. Our desired goal was to improve the documentation of Hep B vaccinations, therefore ensuring that the child's vaccine record was accurate and preventing future over immunizations.
Significance:
Incomplete records can lead to over immunizing children, as well as create a delay in admission to school/daycare for these patients. By improving documentation it saves patients the pain of additional immunizations and indicates our compliance with the CDC's immunization administration guidelines.
Strategy and Implementation:
Baseline data was collected retrospectively on patients seen for a "Newborn" appointment from July 2011. Only 51% of records indicated Hep B #1 documentation in the EHR. This initial Hep B dose is administered at the birth hospital and must be extracted from the copy of the birth record. Data collection was repeated for Sept and Nov 2011 with no significant change. Staff champions were identified. Discussion with all Nurses and CNA's occurred in Dec when a plan was developed to: request the individual immunization record from the parent/caregiver at every appointment & extract immunization data from the birth hospital newborn discharge summary. Staff began to proactively seek out the birth hospital information before the pt's arrival for an appointment. If the newborn discharge documentation was available staff were educated on where to locate this information in the document. CNA's were also educated on how to enter vaccine data into the EHR.
Evaluation:
Retrospective chart review again completed for January, March, and June 2012 to determine compliance with entry of Hep B #1. Documentation consistently improved: January 78%, March 86.5%, & June 95%. Ongoing feedback provided to staff lead to this outcome.
Implications for Practice:
Use of staff champions, frequent reminders of success and our recognition of the need for CNA education on documentation retrieval and entry into the EHR. Staff champions were integral to the process by providing the education and support to the other staff who have various levels of education.