CC-UC-00300 - Primary Health Care: Basic Flow - Immunization Child

Actors

• Client (child - 6 months to 16 years)
• Parent/guardian
• Medical administrator
• Registered nurse (RN)

Pre-conditions

• Client intake and registration has been completed.
• Client is following provincial/territorial immunization schedule.
• Client is covered under provincial/territorial health care insurance.
• Client is on the clinic's roster.
• Clinic system has the capacity for personalized immunization schedules including clinical decision support for forecasting.

Step	Description	Data elements collected	Result
1	Client has arrived at the clinic for a pe-scheduled immunization.	Appointment Service Type Appointment Reason Appointment Period Appointment Type Encounter Status Encounter Start Date and Time	The client is present and ready to begin the immunization encounter. CC-UC-00301 Immunization at school clinic. CC-UC-00302 Immunization at pharmacy. CC-UC-00303 Immunization at travel clinic. CC-UC-00304 Immunization at public health unit.
2	Registered nurse (RN) verifies client's allergy(ies) status and confirms there are no known allergies.	Allergy or Intolerance Status Allergy or Intolerance Status Allergy or Intolerance Category Allergy or Intolerance Type Allergy or Intolerance Clinical Status Allergy or Intolerance Verification Status Allergy or Intolerance Substance Allergy or Intolerance Onset Allergy or Intolerance Exposure Route Allergy or Intolerance Reaction Risk Allergy or Intolerance Date of Resolution Allergy or Intolerance Reaction Allergy or Intolerance Reaction Description Allergy or Intolerance Reaction Severity Allergy or Intolerance Date of Onset Allergy or Intolerance Date of Last Occurrence No Active Medications Flag Medication Reconciliation Complete Flag Indigenous Traditional Medicines Medication Medication Usage Status Medication Usage Status Reason Medication Dose Value Medication Dose Unit of Measure Prescribed Medication Dose Type Medication Route of Administration Medication Timing Medication Timing Period Unit of Measure Medication Usage Start Date and Time Medication End Date and Time Medication Notes	No known allergies are confirmed, and the client's medical record is updated. CC-UC-00305 Client is allergic to immunization compound.
3	RN takes the client's vital signs.	Vital Signs Complete list Baby Vital signs Date and Time of Observation Measurement Type Unit of Measure Body Weight Weight Percentile Body Height Height Percentile Body Mass Index (BMI) Body Mass Index (BMI) Percentile Waist Circumference Body Temperature Body Temperature Measurement Method Blood Pressure Blood Pressure Measure Body Site Blood Pressure Measurement Method Blood Pressure Body Site Blood Pressure Measurement Body Position Heart Rate Heart Rhythm Respiratory Rate Pulse Oximetry Weight for Length Percentile Head Circumference Head Circumference Percentile Adult (2+) Vital signs Date and Time of Observation Measurement Type Body Weight Body Height Height Percentile Weight Percentile Weight for Length Percentile Body Mass Index (BMI) BMI Percentile Waist Circumference Body Temperature Body Temperature Measurement Method Blood Pressure Blood Pressure Measurement Methods Blood Pressure Body Site Blood Pressure Measurement Body Position Heart Rate Heart Rhythm Respiratory Rate Pulse Oximetry Unit of Measure	Client's vital signs are recorded in the medical record. CC-UC-00306 Client has fever.
4	RN provides immunization education and obtains consent from client caregiver.	Document Date and Time Document Status Document Principal Author Document Type Document Recipient Document Content	Immunization education is provided and client/caregiver's consent are recorded in the client's medical record. CC-UC-00307 Consent not given to immunize.
5	RN administers immunizations to client and provides and updates immunization record.	Immunization Reporting Source Immunization Immunization Expiration Date Immunization Market Authorization Holder Immunization Lot Number Immunization Series Doses Immunization Dose Number Immunization Reason Immunization Dose Volume Immunization Dose Unit of Measure Immunization Route of Administration Immunization Site Immunization Date Immunization Status Immunization Performer Role Document Date and Time Document Status Document Type Document Recipient Document Content	Immunization is administered and an updated immunization record is provided and recorded in the client's medical record.
6	RN records the immunization administration in the client's record.	Document Date and Time Document Status Document Principal Author Document Type Document Content	The immunization administration is documented, and the client's medical record is updated.
7	RN instructs the client/client caregiver to remain at clinic for post-immunization monitoring as per local policy.	Post-Procedure Instructions Date and Time of Observation (if commencement of monitoring is documented) Immunization Reaction (only if one occurs) Immunization Reaction Date and Time (if applicable) Immunization Reaction Reporter (if applicable)	The client/caregiver remains at the clinic for post-immunization monitoring, and the client's medical record is updated.
8	The medical administrator schedules a follow-up appointment based on immunization forecasting needs.	Immunization Forecast Status Immunization Forecast Status Generated Date Immunization Forecasting Schedule Date Type Immunization Forecast Date Appointment Service Category Appointment Service Type Appointment Creation Date and Time Appointment Requested Range Appointment Reason Appointment Instructions Appointment Confirmation Status Appointment Period Appointment Type	A follow-up appointment is scheduled and recorded in the client's medical record.
9	Client leaves primary care clinic/public health unit after the appropriate monitoring period.	Date and Time of Observation Encounter Status Encounter End Date and Time Encounter Disposition Immunization Reaction (only if one occurred) Immunization Reaction Date and Time (if applicable)	The client completes the post-immunization monitoring period, leaves the clinic, and the client's medical record is updated. CC-UC-00308 Immunization incident
10	Use case ends.	Not applicable	Not applicable

Post-conditions

• No known allergies are confirmed.
• Immunization education is provided and client/caregiver's consent are recorded.
• Immunization is administered and an updated immunization record.
• A follow-up appointment is scheduled.
• Client's medical record is updated.

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Contact us

If you have questions about this initiative, would like to be added to our stakeholder notification list or would like to participate in our consultations, please email us.

connectedcare@cihi.ca