Canadian Immunization Guide
Seventh Edition - 2006

[Previous] [Table of Contents] [Next]

Part 1
General Guidelines

Immunization Records

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

Pre-printed, peel-off labels and bar coding of products will facilitate such recording. Manufacturers are encouraged to produce these labels and to bar code products. Immunization registries should have mechanisms that will allow bar coded information about the products to be read into the database.

Personal immunization records: Each person who is immunized should be given a permanent personal immunization record. Individuals should be instructed to keep the record in a safe place and bring it to immunization visits. Parents should maintain these records on behalf of their children and pass them on to their children at the appropriate time, such as when they are leaving home. Immunization records may be required for children to attend school or child-care centres. Adults may be required to produce these records in order to work in certain professions, such as health care, teaching or occupations requiring foreign travel. Relevant information, such as rubella and hepatitis B serology or tuberculin skin test results, can also be recorded in the personal immunization record.

Health care provider records: Health care providers must also maintain a record of all vaccinations provided. In addition to information about vaccinations given, the health care provider's record should include all relevant serologic data (e.g., rubella serologic results, hepatitis B surface antibody titres) and should document adverse events following immunization as well as contraindications, exemptions or reasons for deferring vaccination. It is recommended that a summary of immunizations, serologic results and any significant adverse vaccine reactions be stored in an easily retrievable manner that permits regular checking and updating of the individual's immunization status (i.e., immunization information should not be archived in a medical record). Electronic medical records used by health care providers should have the capacity to collect and easily retrieve all required vaccination information. Vaccine providers should forward the immunization information to other providers and/or to agencies, such as public health, as appropriate or required by legislation.

Immunization registries: There are several advantages to maintaining immunization records in a registry. On an individual level, immunization registries prevent immunizations already given by another health care provider from being duplicated.

A comprehensive immunization registry system will serve the following functions:

• Facilitate the timely, accurate recording of all relevant immunization information regardless of where and by whom the vaccines were administered
• Identify children and adults who are overdue for immunizations and generate reminders and recalls for these individuals
• Allow health care providers to review immunization status at each encounter in a confidential, secure manner and produce immunization records for their patients
• Provide data for public health professionals to assess immunization rates, and plan and evaluate targeted interventions for populations with less than optimal immunization rates

Where immunization registries exist, immunization providers should be aware of legislative or other requirements to report immunization information to these registries. Incomplete information can significantly decrease the benefits derived from an immunization registry. Strategies should be employed to maximize participation by health care providers.

Refer to the National Guidelines for Immunization Practices for additional information about the use and maintenance of immunization records.

Selected references

Canadian Immunization Registry Network (CIRN). URL: <http://www.phac-aspc.gc.ca/im/cirn-rcri/index.html>.

Feikema SM, Klevens RM, Washington ML et al. Extraimmunization among US children. Journal of the American Medical Association 2000;283(10):1311-17.

Health Canada. Functional standards and minimum (core) data sets for a National Immunization Registry Network and Vaccine Associated Adverse Event Surveillance System. Canada Communicable Disease Report 2002;28(S6):1-38.

[Previous] [Table of Contents] [Next]