Recording immunisations

Record immunisations in an immunisation clinical item.

Before you administer an immunisation, you can check the vaccines recorded on the AIR that have been administered to the patient and the vaccines due. For more information, see Australian Immunisation Register portal.
To record an immunisation:
  1. In a patient's clinical record, in the footer, select Immunisation > required immunisation.
    Not all immunisations are included in the Immunisation shortcut list.
  2. Alternatively, click Clinical Item iconClinical Item.
  3. In the Clinical Terms Browser, in the Search-words field enter a search term. For example, Immunisation.
    Tip:
    To list all supported COVID-19 vaccines, use the keyword COVID19.
  4. Select the required item in the list and click Select iconSelect.
  5. In the Immunisation clinical item, if you want the immunisation listed on the Summary > Main Summary tab, set Display on Main Summary.
  6. If required, in the Comment field, enter a comment.
  7. In the Performed date field, today's date is selected by default. If you are recording an historical immunisation, set the date for when the immunisation occurred.
  8. If required, in the Actual duration (minutes) field, enter the duration in minutes.
  9. If required, from the Route and Site list, select how and where on the body the vaccine was administered.
    The route of administration is required for some vaccines, for example, Imojev and Jespect; and restricted for others, for example for JYNNEOS.
  10. Where required, from the Vaccine Type list, select the vaccine funding program under which this vaccine is being administered. For example, for Adacel or Engerix-B.
  11. In the Dose (this course) field, enter the dose number for this course.
    For a vaccine given at birth, select Birth or enter B.
  12. Alternatively, in the Dose number field, enter the dose number for this course.
    Note:
    You must include a dose in either the Dose number or Dose (this course) field or the upload of the immunisation record to the AIR will fail. If a value is recorded for both fields, Dose number has precedence.
    Tip:

    A dose number of 0 is interpreted as a birth dose.

    The AIR records vaccine doses at the antigen level, not by brand. Record the dose number based on the number of previous doses of the particular antigen that has been administered. For example, if the DTP vaccine Infanrix Hexa dose 1,2 and 3 are recorded on the AIR for an individual, and DTP vaccine Tripacel is given at 18 months, Tripacel should be recorded as dose 4, because it is the fourth of a DTP containing vaccine; in this instance Tripacel should not be recorded as dose 1.

  13. If you are administering the immunisation today, set Performed at current encounter place. This field is used for the AIR (Done Here) report.
    If you are recording historical immunisations performed elsewhere in Australia, deselect this option.
  14. If you are recording historical immunisations performed overseas, instead set Administered overseas.
    1. From the Country list, select the country or region in which the immunisation was administered to the patient.
  15. If required, in the Vaccine batch field, enter the alphanumeric batch details.
    The vaccine batch number is required for all COVID-19 vaccinations and some other vaccines, for example, Adacel, Pneumovax 23, Shingrix. Letters in the batch number must be uppercase.
  16. The AIR no longer requires you to record a serial number. However, if Serial Number Mandatory is set for an immunisation clinical item, in the Serial Number field, enter the serial number. Alternatively, to use a barcode scanner, ensure the cursor is positioned in this field and scan the barcode.
    For more information, see Clinical Item Type Properties.
  17. From the Vaccine expiry date calendar, select when the vaccine expires.
The immunisation record and selected details are displayed on the Progress Notes and Detail tab. Not all details are displayed.
Example immunisation progress note
The location recorded for the immunisation will be one of the following, depending on the option selected in steps 11-12:
  • Performed at: current encounter place
  • Performed elsewhere
  • Administered Overseas: Yes

Check that immunisations have uploaded to the AIR in File > Online Claiming > AIR Claims tab. For more information, see Australian Immunisation Register uploads.

Follow your own protocols for managing immunisation recalls, immunisation rejections and so on.

Tip:
If the Immunisation Age Based Reviews dataset is enabled, the automated recalls for each age-based immunisation are automatically enabled. If this was an age-based immunisation, from the To Do list on the Summary > Main Summary, double-click the recall to open it and then complete the recall.