# Documenting a Patient’s Immunizations and Skin Tests

Before CPRS v32b (OR*3.0*405) was released, most documentation about a patient’s immunizations and skin tests was listed as free text information in a progress note. However, CPRS now provides clinical computable data when a user documents these items.

When documenting the administration or reading of an Immunization or a Skin Test in all locations, CPRS will automatically add specific Current Procedural Terminology (CPT) and International Classification of Diseases-10 (ICD-10) codes associated with it. CPRS will also add the correct administration CPT codes.

Note: CPRS will not allow you to document an immunization unless it is marked as Active in the Immunization file and has available Lot Numbers for the encounter location. CPRS does not allow you to enter a future date/time for an immunization or skin test.

You can document a patient’s immunization from these locations in CPRS:

- Coversheet
- Immunization tab in the Encounter form
- Reminder Dialogs

You can document a patient’s skin tests from these locations in CPRS:

- Skin Test tab in the Encounter form
- Reminder Dialogs

## Description of the Enter Immunization/Skin Test Screens

Regardless of the location from where you start recording the immunization/skin test, CPRS will always take you to the Enter Immunization or Enter Skin Test screen, which has the following sections:

- Immunization/Skin Test Evaluation Statuses: Lists the immunizations or skin tests.
- Immunization/Skin Test List: Shows the immunizations or skin tests that are in the patient record. If you have accessed the Enter Immunization screen from the coversheet, the Immunization List will be filled in only when a user is currently entering an immunization. If you have accessed the Enter Immunization screen from the Immunization tab in the Encounter form, the Immunization List will always contain a patient’s immunizations.
- Immunization/Skin Test Selection: Allows you to select an immunization/skin test and a documentation type.
- Editor/Detail Viewer: Displays the fields associated with a specific document/skin test type and allows you to edit them.

After you access the Enter Immunization/Skin Test screen, you will be able to add, edit, delete, or view an immunization/skin test.

The examples below show what the Enter Immunization screen looks like when you open it from the Coversheet, and what the Enter Skin Test screen looks like when you open it from the Encounter form.

Example of the Enter Immunization screen
Example of Enter Skin Test dialog

## Accessing the Enter Immunization Screen from the Coversheet

1. Right-click on the Recent Immunizations pane and select Enter New Immunizations on the dropdown.
2. If an encounter location hasn’t been selected, the Location for Current Activities screen will appear, and you will need to select an Encounter Location and Date/Time of Encounter.
3. You will now see the Enter Immunization Screen.

## Accessing the Enter Immunization/Skin Test Screen from the Encounter form

1. On the Encounter Form screen, click the Immunizations or Skin Test tab.
2. On the Immunizations/Skin Test tab, click the Add/Edit/Delete Record button.
3. You will now see the Enter Immunization/Skin Test screen.

## Accessing the Enter Immunization/Skin Test Screen from the Reminder Dialogs

1. Click on the button in the Reminder Dialog that takes you to the immunization/skin test form.

## Adding an Immunization/Skin Test to CPRS

1. On the Enter Immunization/Skin Test screen:
   1. If you are adding an immunization:
      1. On the Enter Immunization screen, select a Documentation Type and an Immunization in the Immunization Selection section.
   2. If you are adding a skin test:
      1. On the Enter Skin Test screen, select a Documentation Type and a Skin Test in the Skin Test Selection Section.
2. Fill in all required fields (marked with an asterisk) for the selected Documentation Type.
3. Click Save.
4. Click Finish. Administered and historical vaccines will be listed on the CPRS Coversheet. Contraindicated and refused vaccines will not be listed on the Coversheet. However, they will be listed on the Encounter Form à Immunizations tab. If a vaccine was contraindicated, you will get a warning message when you click Finish.

## Editing an Immunization/Skin Test in CPRS

1. On the Enter Immunization/Skin Test screen, right-click on an immunization/skin test in the Immunization/Skin Test List section and select Edit Immunization/Skin Test from the dropdown.
2. In the Editor/Detailed Viewer section, update the information about the immunization/skin test.
3. Click Save.
4. Click Finish.

   Note: You can always edit an immunization/skin test if you accessed the Enter Immunization/Skin Test screen through the Immunization/Skin Test tab in the Encounter form. However, if you accessed an immunization through the Coversheet, you can edit it only under this condition: You have added an immunization and saved it, but you have not finished it and have kept the Edit Immunization screen open.

## Deleting an Immunization/Skin Test in CPRS

1. On the Enter Immunization/Skin Test screen, right-click on an immunization/skin test in the Immunization/Skin Test Lists section and select Delete Immunization/Skin Test from the dropdown.
2. Click Save.
3. Click Finish.

   Note: You can always edit an immunization/skin test if you accessed the Enter Immunization/Skin Test screen through the Immunization/Skin Test tab in the Encounter form. However, if you accessed an immunization through the Coversheet, you can edit it only under this condition: You have added an immunization and saved it, but you have not finished it and have kept the Edit Immunization screen open.

## Viewing the Immunization/Skin Test Status in CPRS

1. On the Enter Immunization/Skin Test screen, right-click on an immunization/skin test in the Immunization/Skin Test Evaluation Statuses section and select either View Information or Clinical Maintenance from the dropdown.

   Note: View Information and Clinical Maintenance display the same information about the patient’s immunization history. However, View Information displays the information on the right-hand side of the Immunization Evaluation Statuses section while Clinical Maintenance displays the information on a separate screen and allows you to print it.

2. Click Finish.

Related topics

Cover Sheet

Entering Encounter Form Data