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Vaccination and immunisation record keeping requirements are tightened

by Rima Evans
18 April 2024

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Practices are required to meet new standards on how patient data related to routine vaccination and immunisation is recorded and processed, guidance has confirmed.

The contractual change was first announced in the GP contract letter released in February.

However, NHS England guidance published earlier this week has outlined the steps practices will need to take in more detail.

From this April, surgeries will be required to maintain accurate and up-to-date patient vaccination records, including correcting records when practices are made aware of any errors.

They will need to relevant SNOMED codes to record vaccination events, with the guidance also explaining how vaccination events can be coded retrospectively in different clinical systems.

Current and valid SNOMED codes that are used to ensure practices receive payment for vaccination activity are available at the Primary Care Domain (PCD) Reference Set Portal, NHS England advised.

Meanwhile, vaccination status will need to be recorded for all patients, including those who have arrived from overseas or from another setting, according to the guidance.

It said that in the case of the latter, where they have ‘a documented or reliable verbal history of immunisation, then the practice can assume the person is immunised and record the details as such in the GP patient record – noting that in the case of reliable verbal histories, it may not be possible to record the batch number or exact vaccination date’.

However, where children and adults come to the UK and do not have a documented or reliable verbal history of immunisation, ‘practices should assume the person is unimmunised and a full course of required immunisations should be planned’, as set out in the Green Book.

In addition, surgeries will have to share vaccination status data (both vaccinated and unvaccinated with the local Child Health Information Service (CHIS) and any other system nationally required by NHS England.

The standard on data quality now joins the other contractual requirements for vaccination and immunisation services, which include standards for call/recall programmes, provision of appointments and participation in national agreed catch-up campaigns.

Although the standards apply to the vaccination programmes outlined in the Statement of Financial Entitlements (such as childhood routine immunisations like MMR and adult routine vaccinations like Shingles) practices are encouraged to use them for seasonal vaccination programmes too, where appropriate.

NHS England said it recognised that most practices were already working to the vaccination and immunisation standards and core contractual requirements, but ‘where practices may not be achieving against them, this document will support practices in understanding what is required to meet them’.

Records for each vaccination event should cover:

  • any refusal of immunisation
  • where an offer of immunisation is accepted
  • details of the informed consent to the immunisation
  • the batch number, expiry date and name of the vaccine
  • the date of administration
  • when 2 or more vaccines are administered in close succession, the route of the administration and injection site of each vaccine
  • any contraindication to the vaccine or immunisation
  • any adverse reaction to the vaccination or immunisation.

Source: NHS England