CC-UC-00303 - Immunization at Travel Clinic

Actors

• Client (child 5+, adult 18+)
• Caregiver/parent/guardian
• Medical administrator
• Registered nurse (RN)

Pre-conditions

• The client has arrived for a prescheduled appointment.
• The client requires an immunization that is not covered by provincial/territorial health insurance.

Step	Description	Data elements collected	Result
1	Registered nurse (RN) completes assessment of client's health history.	Health Concern Reporting Source Health Concern(s) Health Concern Date of Onset (if applicable) Health Concern Date of Resolution (if applicable) Health Concern Clinical Status Health Concern Category Health Concern Verification Status Medication Medication Usage Status Medication Reason Medication Statement Date and Time No Active Medications Flag (if applicable) Family History Status (if relevant to the assessment)	Health history assessment completed and recorded in the client's medical record.
2	RN evaluates client's itinerary and recommends immunization based on Health Canada, World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) requirements.	Immunization Guideline Name Immunization Guideline Authority Immunization Guideline Target Disease Immunization Forecast Status Immunization Forecast Status Generated Date Immunization Forecasting Schedule Date Type Immunization Forecast Date	The client's travel immunization requirements are determined, and the client's medical record is updated.
3	RN verifies client's allergy(ies) status.	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	Allergy status is verified and details are recorded in the medical record. CC-UC-00305 Client is allergic to immunization compound.
4	RN takes the client's temperature.	Date and Time of Observation Measurement Type Unit of Measure Body Temperature Body Temperature Measurement Method	Client's temperature is taken and recorded in the client's medical record. CC-UC-00306 Client has fever.
5	RN provides immunization education and obtains consent from client.	Document Date and Time Document Status Document Principal Author Document Type Document Recipient Document Content	Immunization education is provided and consent is obtained, and recorded in the client's medical record. CC-UC-00307 Consent not given to immunize.
6	Medical administrator charges client/client caregiver immunization fees for services not covered by provincial/territorial health insurance.	Immunization Funding Source Immunization Program Eligibility	The Client/client caregiver is charged and pays the applicable fees.
7	RN administers immunization(s) to client.	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	Immunization is administered and the details are recorded in the client's medical record.
8	RN/ instructs 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 recorded) Immunization Reaction (only if a reaction occurs) Immunization Reaction Date and Time (if applicable) Immunization Reaction Reporter (if applicable)	Client/client caregiver remains at the clinic for post-immunization monitoring.
9	The RN provides the client with an updated immunization record.	Document Date and Time Document Status Document Principal Author Document Type Document Recipient Document Content	An updated immunization record is provided and recorded in the client's medical record.
10	Client leaves the travel clinic after the appropriate monitoring period.	Date and Time of Observation (if completion of the monitoring period is recorded) Immunization Reaction (only if one occurred) Immunization Reaction Date and Time (if applicable)	The client leaves the travel clinic. CC-UC-00308 Immunization incident.
11	This use case ends.	Not applicable	Not applicable

Post-conditions

• Client health history assessment is completed.
• The client's travel immunization requirements are determined.
• Allery status is verified.
• Immunization education is provided and consent is obtained.
• Immunization is administered.
• An updated immunization record is provided.
• Applicable fees for service are charged and payment is processed.
• Client's medical record is updated.

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