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Documentation is for the correct beneficiary and date of service. Documentation includes physicians order for date(s) of service when medication(s) were administered, to include the medication name, dosage, frequency, and method of administration.
Diphtheria, Tetanus, and Pertussis Vaccine Information Statements. DTaP (English / Other Languages) Td (English / Other Languages)
For example, documentation should list all vaccine components along with a notation such as counseling for all components completed. The documentation format (eg, checkbox, handwritten, electronic template) for this service should be the same as for other services.
Obtain the Childs Personal Immunization Record The personal immunization record must: ✓ identify the student by name and date of birth ✓ show the date (month, day, and year) each required vaccine dose was received ✓ have the type of vaccine received ✓ include the name of the physician or agency who gave the vaccine.
CDC recommends 1 dose of Tdap for all adolescents. The preferred age for Tdap administration in adolescents is 11 to 12 years. If adolescents (13 through 18 years) missed getting Tdap at 11 to 12 years of age, administer at the next patient encounter or sooner if adolescent will have close contact with infants.
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By law, the following information must be documented on the patients paper or electronic medical record (or on a permanent office log): The vaccine manufacturer. The lot number of the vaccine. The date the vaccine is administered.

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