A dated, timed, and signed physician order for recommended vaccines will be documented on the physician order form. If any recommended vaccines are not ordered, there must be clear documentation indicating the rationale for why one or more vaccines were not ordered. Doing so will facilitate clear communication along the continuum of care.

Vaccine administration documentation on the medication administration record (MAR) will include date, time, dose, lot number/lot sticker, manufacturer, and nurse signature for each vaccine. If any or all of the vaccines are ordered, but not administered (for any reason), the ordering physician must be notified, and there must be clear documentation indicating this and the rationale for why one/more vaccines were not administered. Also, document which provider was notified. This facilitates clear communication along the continuum of care.

Documentation in the electronic medical record for the physician order, dispensing from the pharmacy or immunization clinic, and nursing administration is preferred when possible. Documentation of vaccination is highly recommended in the service specific vaccination tracking systems (MEDPROS for Army, MRRS for Navy/Marine/Coast Guard, and ASIMS for Air Force) if available at the treating facility or operating base.