1. While considering what providers are responsible for, documentation-wise, it’s also important to keep in mind what providers are not on the hook for.
Most of the heavy lifting generally falls on the entity actually putting shots in the arms. As a corporate Walgreens spokesperson said, “Walgreens will be reporting all vaccines/doses administered to the CDC and state immunization registries.”
As the CDC notes, any entities that actually administer vaccines are required to document vaccine administration in their medical record systems within 24 hours and use their best efforts to report administration data to the relevant system for the jurisdiction as soon as practicable.
However, Walgreens added, it is “leaving documentation of vaccine recipients for the facility.”
2. Be fully aware of provider responsibilities.
Actually, nursing homes play a key role in documenting the COVID-19 vaccine rollout and are the only type of long-term care setting affected. They will be heavily scrutinized for getting it right. Two members of Congress in early January urged the federal government to regularly post fresh LTC vaccination data in the MDS, and on Nursing Home Compare.
Facilities are required to register residents online and complete consent forms, and for each person getting the vaccine, document administration date, vaccine manufacturer and lot number, individual who administered the vaccine and address where the permanent record resides. Also required is a dated vaccine information statement and when it was tendered to a family member.
John Ederer, president of American Data, urged facilities to document and “track all services they provide related to COVID-19, even if those services are provided by a pharmacy or other provider,” including physician orders, side effects, allergic reactions and second dose dates.
Claire Stephens, senior vice president, Post-Acute, American HealthTech, echoed Ederer’s advice as a backup for potential liability concerns.
“As this is a new vaccine against a new virus, it is important to monitor each person receiving it and documenting any unexpected side effects,” said Debi Damas, RN, Prime Care Technology’s senior director of Customer Success-Applications. “This information will be very important to help develop guidance on who should or should not get the vaccine down the road.”
Facilities must also report the following data to the CDC’s National Healthcare Safety Network: counts of deceased residents and staff, newly suspected and lab-positive cases; staffing shortages; PPE availability; ventilator capacity; and supplies for ventilator units.
Providers using point-of-care rapid response testing for staff and residents must also regularly report back data they generate.
3. Voluntary reporting and documentation is a key aspect of the process.
Walgreens adds that facilities are encouraged, but not required, to report pharmacy-administered vaccines to NHSN, with Walgreens providing documentation.
Facilities also are encouraged to report adverse events through the CDC’s Vaccine Adverse Event Reporting System, and to have staff use the “V-safe” app to receive second-dose reminders, participate in surveys and text with CDC officials following vaccinations.
Genice Hornberger, senior product advisor at PointClickCare, reminds providers of the FDA requirement that vaccine recipients or their caregivers be provided with vaccine-specific Emergency Use Authorization information to help make informed decisions. In any case, she urged SNF leadership “to ensure the team is clear on all the pertinent regulations they must abide by, to avoid any compliance issues.”
4. The value of the electronic medical record must be appreciated.
IT companies remind facilities to exploit the ability to integrate all COVID-19-specific information into residents’ medical records.
A.J. Peterson, vice president and general manager of interoperability for Netsmart, encouraged facilities to use EMR reporting capabilities to schedule vaccination. “As COVID-19 vaccines are distributed, it is critical we avoid vaccine wastage and spoilage,” Peterson said. “This is where scheduling becomes key with second doses.”
Stephens urged providers to exploit their EMRs’ capability to record data such as side effects and vaccination dates in real time, rather than end of shift, to ensure accurate documentation. “This not only avoids mistakes but also produces more accurate data analytics for better outcomes,” she added.