Immunization records: Canadian Immunization Guide

For health professionals

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Updated: February 2016

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• Introduction
• General Considerations
• Personal Immunization Records
• Health Care Provider Records
• Immunization Registries
• Selected References

Introduction

Immunization records are a crucial component of the immunization process. This chapter provides information and guidance about the use of immunization records and their contents. For information about immunization of individuals with inadequate records, refer to Immunization of Persons with Inadequate Immunization Records in Part 3.

General Considerations

Recording immunizations

Vaccine providers should record in the following three locations, on paper or electronically, vaccines administered to an individual:

1. the personal immunization record held by the vaccine recipient, or his or her parent or guardian;
2. the record maintained by the health care provider who administered the vaccine;
3. the local provincial or territorial immunization registry (if one has been established).

Immunization record contents

Vaccine providers should include the following information in each of the above three locations:

• the brand name of the administered product;
• time and date of administration;
• quantity of administered dose (if applicable);
• anatomical site of administration;
• route of administration;
• lot number of the product and expiry date;
• name and professional designation of the person administering the product (this information may not be required in provincial or territorial immunization registries).

Vaccine providers should record additional relevant information, such as rubella or hepatitis B serology or tuberculin skin test results, in the personal immunization record, as well as in the record maintained by the health care provider.

Product manufacturers are encouraged to provide peel-off labels and to provide bar codes for products to facilitate recording of product information. Pharmacists who dispense vaccines should consider providing peel-off labels if they are not provided by the manufacturer.

Personal Immunization Records

Each vaccine recipient should be provided with a permanent personal immunization record. Vaccine recipients, or their parents or guardians, should be instructed to keep the record in a safe place and to present it at every health care visit so that it can be updated. If the personal immunization record is not available at the time of vaccination, the vaccine provider should ensure that adequate information is given so that the vaccine recipient or his or her parent can update the personal immunization record with the information outlined in Immunization record contents. Parents should maintain these records on behalf of their children and give them to their children at the appropriate time, such as when they are leaving home. An example of an adult personal immunization record is available from Immunize Canada. Electronic immunization record keeping that allows online access by vaccine recipients and health care providers should be encouraged as it becomes available.

Immunization records may be required for children to attend school or child care centres. Adults may be required to provide immunization records to be eligible to work in certain professions, such as health care, teaching or occupations requiring international travel.

Refer to National Guidelines for Immunization Practices in Part 1 for additional information about personal immunization records.

Health Care Providers Records

Health care providers must maintain a record of all vaccines that they administer and must ensure that information is accurately and completely recorded. In addition to recording information about the vaccines given (refer to Immunization record contents), providers' records should include:

• all relevant serologic data, for example, rubella or hepatitis B serology);
• documentation of adverse events following immunization;
• documentation of contraindications or reasons for deferring or withholding immunization;
• other immunization related documentation, such as pre-vaccine and provider administration check lists (refer to Vaccine Administration Practices in Part 1 for more information).

Electronic medical records used by health care providers should have the capacity to record, to collect and to retrieve easily all information outlined in Immunization record contents, and should permit production of line listings of persons who received a specific vaccine in the event that the vaccine is recalled.

At each immunization visit, information should be sought regarding adverse events that may have occurred following previous doses in an immunization series. Vaccine providers should fully document all clinically significant adverse events in the medical record as soon as they become aware of such an event.

Vaccine providers should maintain easily retrievable summaries of vaccination records to permit regular checking and updating of the individual's immunization status, as well as the identification and recall of individuals, especially children, who are delayed in the recommended immunization schedule. It is useful to record all immunization related information on a single sheet or in a separate section of the vaccine recipient's chart. Immunization information should be readily available and should not be archived in a medical record.

Vaccine providers should facilitate the transfer of information in the immunization record to other health care providers and to appropriate agencies in accordance with requirements, such as provincial legislation. When a health care provider who does not routinely vaccinate or provide care to an individual administers a vaccine to that individual, the regular health care provider should be informed.

Refer to National Guidelines for Immunization Practices in Part 1 for additional information about the use and maintenance of immunization records.

Immunization Registries

Immunization registries are centralized, confidential, electronic information systems that record doses of vaccines administered and maintain vaccination histories to ensure accurate and timely immunizations. All provinces and territories should develop and maintain electronic immunization registries. A comprehensive immunization registry system:

• facilitates timely, accurate recording of all relevant immunization information, regardless of where and by whom vaccines are administered;
• prevents duplication of immunizations given by another health care provider;
• identifies persons who are overdue for immunizations and generates reminders and recalls for these individuals;
• allows health care providers to review the individual's immunization status at each encounter in a confidential, secure manner;
• provides data for public health officials to assess immunization rates and coverage, and to plan and to evaluate targeted interventions for populations with less than optimal immunization rates;
• assists with planning upcoming immunization visits;
• assists with inventory management of immunizing agents;
• enables timely and efficient evaluation and planning of immunization programs.

Where immunization registries exist, vaccine providers should be aware of legislative or other requirements to report immunization information to these registries because incomplete information can significantly decrease the benefits derived from an immunization registry.

Selected References

• Health Canada. Functional standards and minimum (core) data sets for a National Immunization Registry Network and Vaccine Associated Adverse Event Surveillance System. Can Commun Dis Rep 2002;28(S6):1-38.
• Public Health Agency of Canada. Canadian Immunization Registry Network (CIRN). Accessed July 2015 at: http://www.healthycanadians.gc.ca/healthy-living-vie-saine/immunization-immunisation/index-eng.php.

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