You can record patient immunizations or other types of injections from the Injections section of an encounter to document the immunization as part of the visit. Or, you can record an immunization from the Injections area of the patient's chart.
You can manually type injection names or, if commonly-used injections were added to the clinic-wide list, you can select from a list of matches. To save time and allow consistent entry across users, you should select an injection from the list whenever possible. For more information about adding immunization and injection templates, see Managing clinic-wide frequent injections.
Steps
1. Open the patient's chart or start an encounter for the patient.
If you have an encounter open, in the Injections area of the encounter, click + Add Injection.
If you don't have an encounter open, from the patient's chart, in the Quick Menu or the Start/Open menu, choose Injections. The Injections area opens and displays a list of the patient's active injections. Click + New Injection.
In Summary view, click the + icon beside the Injections folder.
2. The New Injection window appears, and any recorded allergies for the patient are displayed for your reference.
3. In the Name field, start typing the name of the injection.
If the immunization exists in the clinic-wide list, select it from the list of matching injections. The Type will auto-populate.
💡 Tip: Injections that are part of your clinic-wide Injections list show a blue house with a star icon.
If the immunization or injection does not exist in the list, type the full name in the Name field and select the Type of injection (Allergy, Immunization, Injection, Other).
4. Complete the remaining fields, as appropriate.
📌 Note: If you selected an injection from the list of matches, many of these fields may already be filled out for you. Make any changes, where necessary.
Field | Description |
Dose | Type the amount injected, and select a unit from the list. e.g. 0.5 mL |
Trade Name | The brand name of the injection. |
Drug Code | The DIN value. |
Manufacturer | The manufacturing company of the immunization or injection. |
Site Given | From the list, select the location on the patient's body where the injection was administered. e.g. Left Deltoid, Right Thigh etc.
If the site is not available in the list, select Other and optionally record the site in the Comments field. |
Route | Select the route of administration from the list. e.g. Intramuscular, Intradermal etc.
💡 Tip: If the route is not available in the list, select Other and optionally record the route in the Comments field. |
Series | If the injection is part of a series, select which injection this is from the series. e.g. Booster, Primary etc. |
Lot Number | Type the lot number of the injection.
Or, if you selected an injection from the clinic-wide list and it has more than one lot number recorded, select the appropriate lot number from the list.
💡 Tip: You can also add the expiry date in this field. |
Sequence | Legacy; no longer used. |
Strength | Type the strength of the immunization. e.g. 60 mcg. |
Expiry Date | Click the calendar icon and select a date, or manually type the date. |
Injected By | Defaults to the current user.
Select a user from the list if you are recording an injection performed by someone else. |
Injected Date | Defaults to the current date. Click the calendar icon and select a different date, or manually type a different date, if the injection was not performed today. |
Injected Time | Click the clock icon and select a time, or manually type the time. |
External | Record injections that you did not administer. When selected, Injected By becomes a free text field. |
Historical | Select this checkbox if you are recording an injection a patient had in the past (i.e. was not given today). |
Refused | Select this checkbox to record that you offered this injection but the patient refused. The Injected Date is cleared, and you can enter the Refused Date instead.
Refused injections are recorded in the list of the patient's active Injections, but are clearly labelled Refused.  |
Instructions | Any instructions required. |
Comments | Type any notes about the injection such as side effects, or reason for refusal if the injection was refused. |
💡 Tip: To quickly save your settings to your clinic-wide Injections list, click the Add to clinic-wide injection list checkbox.
5. Click Save when you are finished. The injection is added to the list of the patient's injections (see Viewing a patient's injections for more information).
Updated July 9, 2024