Where it is on screen
Open the appointment. On the left, the Immunization summary lists each vaccine for each person with its informed consent, clinical assessment, administration and observation. When there is more than one row, click a row: the rest of the screen acts on that person and vaccine.
On the right, the Workflow lists the visit's steps: Check in, Start, Informed consent, Clinical assessment, Administration, Post-vaccination observation, Complete. A done step shows a green tick and a summary; the open step shows what to do. A step that does not apply (for example the assessment after a declined consent) reads Not applicable. A step you can already act on, such as sending a consent link before check-in, opens from its label.
The steps before Given
A vaccine can be recorded as Given only after all of these, in this order:
Consent is recorded and the vaccine is accepted (by link, on this device, or verbally).
Screening answers are recorded.
A pharmacist signs the clinical assessment with Proceed with immunization for the vaccine.
Not given can be recorded at any time (for example, the patient declined or left).
Recording verbal consent
Pharmacists only. In the Informed consent step, choose Verbal, then Record verbal consent. Patient declined consent opens the same dialog with the vaccine set to Declined.
Consent. Pick the person (when the booking has several), who is giving consent (the patient or a substitute decision-maker), and Accepted or Declined for each vaccine. Check all nine items under I explained. A vaccine left blank stays waiting for consent.
Screening. If any vaccine is accepted, the button reads Next: screening questions. Ask each question and record the answer. Anything that may defer or contraindicate is flagged for the assessment.
Save consent and screening. Consent and screening are saved together. Nothing is saved until you press it.
Back returns to the consent step with your choices kept. Coming forward again keeps the answers you gave, except for a vaccine you no longer accept.
Closing the dialog on the screening step asks Discard consent and screening? first, because nothing has been saved yet.
If someone records consent for the same vaccine on another device while you are in the dialog, the screening step says so and asks you to go back and check the decisions.
If every vaccine is declined, there is no screening: Record verbal consent saves straight away.
Written consent: Complete on this device hands the device to the patient, and Send consent link texts or emails a link. A link that is out shows its status, with Resend and Revoke link.
The clinical assessment (pharmacist)
The Pre-immunization screening card on the left lists the answers. Flagged shows only the answers that need attention (tinted, with what they mean); All shows every answer. While the assessment is the open step, the card is outlined and labelled Review for clinical assessment.
In the Clinical assessment step, choose Proceed with immunization, Defer, Contraindicated or Refer to physician (a reason is required for anything but Proceed), then Sign assessment. It is signed in your name and OCP number from My profile.
When Sign assessment is greyed out, the reason is shown under it:
Shown under Sign assessment | What to do |
Record the screening answers first (button above) | Press Record screening answers, then sign |
Choose an outcome for at least one vaccine | Pick an outcome |
Add a reason for each outcome other than Proceed | Type the reason |
To change a signed assessment, click Revise beside the done step.
When screening is missing
A verbal consent recorded without its screening (before this was changed, or from another device) shows Next step: record the screening answers in the screening card and in the assessment step, with a Record screening answers button. It opens the screening questions for that consent. A pharmacist, technician, intern or student can record them; once saved, the pharmacist can sign the assessment.
The screening is recorded once. To change it after it is saved, withdraw the consent and record it again.
Giving the vaccine
The Administration step opens on Given once the assessment says Proceed. Confirm the product, lot and site, then Record administration. Until then Given is locked, and the step shows what is missing and a button to go to it:
Step shown | Meaning | Button |
Consent missing | No consent decision for this vaccine yet | Record verbal consent (pharmacist) or Send consent link |
Consent declined | The person declined this vaccine | None. Record it as Not given |
Screening missing | Verbal consent is recorded, the screening is not | Record screening answers |
Pharmacist review missing | Screening is recorded, the pharmacist has not assessed it | Go to the review (pharmacist) |
The assessment outcome was not Proceed | The assessment chose Defer, Contraindicated or Refer to physician | Change review (pharmacist) |
No button appears when your role cannot do that step; ask a pharmacist. When the vaccine will not be given (declined, or the assessment outcome was not Proceed), Administration reads Not applicable; open it from its label to record it as Not given.
Observation and the record
After a dose, the Post-vaccination observation step shows the time remaining, even when the appointment has not been started yet, or has been cancelled or marked as a no-show. End observation: no adverse event ends it (before the planned time it asks first), Report adverse event (AEFI) opens the report, and Patient left early records that.
The Immunization record card on the left shows what was recorded: consent, the assessment, the dose, the next dose (with Book dose 2 when one is due), the observation, adverse events and every amendment. To correct a dose, click Amend beside the Administration step (or Amend administration record under Other actions); each change is logged with a reason. Open patient record under Other actions opens the printable record.
Good to know
The Immunization summary shows Screening needed in the Clinical assessment column when a vaccine's screening is missing.
Only a pharmacist can record verbal consent or sign the assessment. Technicians, interns and students can record the screening and the dose; a non-pharmacist giving the dose names a supervising pharmacist.
The pharmacist who signed the assessment is recorded as the assessing pharmacist on the dose.