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. (See Managing clinic-wide frequent injections for more information on adding injections to the list). To save time and allow consistent entry across users, you should select an injection from the list whenever possible.

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 with a list of the patient's active injections displayed. Click + New Injection.

2. The New Injection window appears, and any recorded allergies for the patient are displayed for your reference.

3. Start typing the name of the injection in the Name field.

  • If the immunization exists in the clinic-wide list, select it from the list of matching injections. The Type will auto-populate.

  • 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

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.

If the route is not available in the list, select Other and optionally record the route in the Comments field.

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.

Sequence

Legacy; no longer used.

Strength

Type the strength of the immunization. e.g. 60 mcg.

Series

If the injection is part of a series, select which one in the series it is from the list. e.g. Booster, Primary etc.

Injected By

Defaults to the current user. Select a user from the list if you are recording an injection performed by someone else.

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.

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.

Serum

Legacy; no longer used.

Comments

Type any notes about the injection such as side effects, or reason for refusal if the injection was refused.

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 October 6, 2021

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