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Competency #10: Documentation

This competency documents information relevant to each immunization encounter in accordance with national guidelines for immunization practices and jurisdictional health information processes.

Learning Objectives

The health professional will be able to perform the following:

  • Describe the role and importance of immunization records.
  • Identify the information to be documented on an immunization record.
  • Record an immunization encounter on the appropriate documentation instruments accurately and completely.
  • Facilitate the transfer of information in the vaccination record to other providers and to appropriate agencies in accordance with requirements.
  • Record the reason and planned follow-up action when a scheduled immunization is not given.


The Canadian Immunization Guide outlines the following as the standard for immunization documentation

Vaccines administered to an individual should be recorded in three locations:

  • the personal immunization record held by the person or his or her parent/guardian;
  • the record maintained by the health care provider who gave the immunization; and
  • the local or provincial registry.

Each method of recording should include the following:

  • trade name of the product
  • disease(s) against which it protects
  • date given (day, month and year)
  • dose
  • site and route of administration
  • manufacturer
  • lot number
  • name and title of person administering the vaccine

Clinical Practice Guidelines

Back to Section 03 – Essential Immunization Practices

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