Data Entry Guidelines - the San Diego Immunization Program Website!
Contents
1. 4 Logout 1 Patients Clicking on Patients will take you back to the main search screen 2 Administration for regular users Clicking on Admin will open a screen with four sections a Password b Vaccinator c Vaccine Inventory d Facility a Password Click here to change your password b Vaccinator Click on words Add new vaccinator for your site Several fields on the bottom will appear with the following choices 1 Vaccinator name Enter entire first name followed by a space then enter the last name followed by a comma Then enter initials for credential e g LVN RN MA MD etc without any punctuation Note If two people have the same name and creden tial enter a middle initial followed by a period after the first name for both individuals 2 Facility name A drop down box with choices for your provider organization will ap pear Click on the appropriate one to choose that facility 3 Today Flag Select Y for yes if that person will be giving immunizations that day Select N for no Only those marked Y will appear in the drop down box in the Im munization screen c Vaccine Inventory Click on the words Vaccine Inventory and then click on Add New Vac cine Inventory to update your inventory Several fields are marked with an asterisk and are required The next screen below the inventory list will have the following choices 12. The report can exclude inactive patients and patients who have only had one immunization visit with the provider facility Description of CASA Report from the Centers for Disease Control and Prevention CDC Page 10 11 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES Up to date status of the defined age group served by the clinic or practice Up to date status of children at critical age markers Antigen specific levels Proportion of children who drop out of the vaccination schedule Extent of missed opportunities Reminder and recall letters and postcards http www cdc gov vaccines programs cocasa default htm d TB These reports are no longer used by the County s TB program and will be replaced with new reports in the near future Administration only available to SDIR Administration and Help Desk Clicking on Admin will open a screen with five sections a Manual Verification b Lookup Ta ble Mgmt c Password d Vaccine Inventory and e Facility a Manual Verification Clicking on these words will open up a patient demo graphic record that is similar to another record However the computer could not automatically match the record so the user must do so You are presented with a drop down box to choose how you matched the two records either by the patient parent or operator user b Lookup Table Management Clicking on these words will open up the follow ing choices
3. Vaccine Choose from the drop down box Be sure to check for the correct type for pedi atric lt 13 adolescent 13 18 and adult 18 2 Lot Number Enter only the lot number Use capitalized letters Do not add any other characters or codes that may be used in other inventory methodology specific to your pro vider 3 Incoming Date The date the vaccine arrived at the facility Follow General Rules for dates 4 Quantity on hand Enter the amount of inventory you have 5 Quantity This is the total number of doses you have of that vaccine 6 Adjustment Quantity Put in the total number of vaccines lost due to expiration wastage or breakage 7 Adjustment Comment Comments on why there are adjustments in the vaccine quantity Up to 255 characters are allowed 8 Manufacturer A drop down box will allow for the user to click on the correct manufac turer of the particular vaccine that is being entered into the inventory 10 Expiration date Type in the expiration date for the vaccine inventory Follow general rules for dates 11 Use today Click on arrow and a drop down box will appear Choose yes or no to in dicate whether that inventory will be used for immunizations that day Page 10 10 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES REPORTS TAB 3 Reports By clicking on Reports you will open four choices a Immunization b Re minder c Export and
4. bad phone bad area code County County of residence of the patient parent Country Country of birth of the patient School School that the patient attends if appropriate Physician Field is auto populated with primary physician s name Birth Country Drop down box permits three choices of country of birth of the patient Unknown Mexico United States IMMUNIZATION TAB Immunization General Patient Update Screen This information is located on the top left on the screen The following information is automatically entered and should be read to verify that the correct patient s immunization record is seen First line e Type of User Administrative User Read only e Name Name of User e Provider Name of Provider Page 10 5 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES e Facility Name of Facility or Site Second line e Last name first name patient s last and first name e Date of Birth of patient e Years and month of patient The information below is visible to the user Some fields will be auto populated and others require the user to choose or type in the information You will need to decide if you want to view unique records includes valid and invalid immunizations and booster doses valid immunizations only or all immunizations given includes duplicate immunizations immunizations given too early etc Unique Valid All Records Buttons You will need
5. O other Section of the manual Topic Page number s Please comment on any of the above and or note other ideas you have to improve the user manual data entry guidelines or the SDIR application in general If you would like the SDIR Manager to call you please give us your name and phone number and a good time to reach you OO a ee Best time day to call Thank you for taking the time to help us to serve you better Page 10 13 12 09
6. Page 10 3 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES Right Side Middle of the Screen Change Click here to change the confidentiality status Yes or No of the patient s record based on the patient or parent decision Be sure to have the patient parent or guardian sign the Stop Start Sharing Request Keep the form in the patient file e Archive Click on this word to archive remove the patient record from the database A new box will open up and you will be asked again if you want to archive or remove the record If you do you are asked to indicate the reason for archiving Click on the arrow at the right side of the box and a drop down box will appear The choices are Duplicate patient Nota patient moved out of registry Nota patient deceased Nota patient joined a provider not on the registry Link Click to search for other duplicate or similar patients records Unlink Click to unlink one patient record from another Sibling Click to create a new record for a sibling of this patient Should only be used if you are absolutely sure that there is no existing record for this patient Show IZ Click to bring up the immunization screen Print Click to print the demographic information Other Screen The Other section is for additional demographic information regarding the patient or the patient s guardian if relevant and can be found in the Add Patie
7. d TB An explanation of each choice follows a Immunization Clicking here will give you four choices 1 Assessment Report This report is a list of all immunizations given and who entered or modified the data There are two forms of the report under this section Detailed and Summary The Detailed Report generated as the Patient Record Activity Re port is a list of data entry activities summarized by patients for the dates specified the Summary Report User Activity Report is the same information but organized by user Inactive patients can or cannot be included in the list 2 Daily Immunization Report This report is a list of all children who received shots on a specified day and a list of who entered the data A total number of patients and im munizations is calculated 3 Vaccine Usage Report This report is helpful to providers receiving vaccines from the county s Immunization Program This report provides a summary of the number of shots given over a specified time period by doses and specified age groups 4 Vaccine Profile A useful report for providers in the Vaccines for Children VFC pro grams It compiles a summary of immunizations by VFC eligibility and age groups b Reminder Reports There are two reports under this section Reminder Outreach and Activity Reports 1 Reminder Outreach These reports may be used by providers to track activities to reach children who need r
8. vaccines individuals others 1 Vaccines Holding the cursor over the word Vaccine will made a drop down list appear with the following choices Medical Vaccines MFG Vac cines MFG Validation Group Vaccine Group Vaccine Combo 2 Individuals Holding the cursor over the word Individuals will bring up Vaccinators to the left Clicking on vaccinator will bring up a list of vacci nators for that facility Clicking on the words Add new Vaccinator will bring up a screen below the Vaccine Inventory list to add new names to the list and to flag who will be giving vaccinations that day by selecting yes By selecting current vaccinators you can enable the drop down box on the Add Immunizations button on the Immunizations screen to be auto populated with those individuals names 3 Others Clicking on Other will bring up the word Message to the left You can write a message This feature is not currently enabled to senda message Page 10 12 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES TRAINING MANUAL User Feedback We invite your comments and ideas on how to improve this guide Please take a moment to complete this form and send it via email or fax 619 692 6619 Your feedback will help us to improve our ser vices Please pick the best description of your familiarity with the SDIR O Beginning user O Intermediate user O Advanced user
9. SCREENS FOUND IN SDIR DEMOGRAPHIC TAB The Patient section at the top of the screen contains demographic information about the individual and parents guardians Patient Top Half of Screen e Last Name Last name of patient only Do not include suffixes such as JR SR Il Ill etc Follow the General Rules for names Required field e First Name First name of patient only Do not include middle name suffixes or prefixes Follow General Rules for names Required field e Middle Name Middle name of patient Follow General Rules for names e Gender Drop down box with choices Male Female Unknown Default setting is Unknown Required field e DOB Date of Birth of patient Follow General Rules for dates Required field e Verify When you are unsure if the record is or is not for the correct patient there are three methods of verification 1 You can go with the computer s automatic match merge process 2 verify that you the operator or user believe it is the right individual or 3 have the patient parent verify it is the right person Required field e Address 1 Enter the residential street address of patient Follow General Rules for addresses Page 10 2 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES e Address 2 Additional residential address of patient Can be used to enter neighborhood area in Mexico Follow General Rules for addresses e City City
10. Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES Data Entry Guidelines FREQUENTLY USED INSTRUCTIONS AND DEFINITIONS Auto populated or Defaulted The computer automatically fills this field Most auto populated fields can be overridden by information entered by the user Click Left click on mouse once Drop down box When you see a drop down box you should place the mouse cursor on arrow at right and hold A list of options will appear Move the cursor to the correct item on list click and release Make sure that item is selected Field A field is an element of a database record used to store information In the case of this application a field is indicated by box or words that when clicked or chosen can be used to enter or choose different data options GENERAL RULES THESE ARE ALWAYS TRUE The following are rules for entering data into and storing information in the Registry Click on the mouse just as you would while web surfing If you see a hyperlink link that is underlined or a button click once to activate it Be careful always to click once then wait Do not double click Patient Names Names should be entered as self reported by the patient or parent guardian Obtain verification from patient if name contains an apostrophe or hyphen Only letters apostrophes and hyphens are allowed Birth Dates Users should type zero 0 in front of 1 digit days and months Type out the birth year with 4 digits For example fo
11. atment Click on Treatment to open the Latent TB Module TB Treatment screen To add new treatment information click on words Add new TB treatment located on the far right Next Due Date Outcome Click to add next due date and the outcome of treatment ACTIVITY LOG Display box Drop down box opens with the following choices of activities you want to see dis played Choices are link record confidentiality mark record confidential or remove confidentiality recall unlink record save record case management reminder error correction error encounter all Add new Activity log Click on these words to open a box to add new activity Fields in this area are Log id This field is auto populated Log type Drop down box appears with the following choices encounter reminder case man agement recall Log date This date is auto populated Notes You can type custom notes on the activity in the space Up to 255 characters are al lowed R SAVE TAB By clicking on the Save Tab you will save any updates However click on the Save tab only after you have entered all information about the patient Page 10 9 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES UTILITY TAB By clicking on the Utility Tab you will open to four new tabs 1 Patients 2 Administration for regular users 2 Administration only available to SDIR Help Desk 3 Reports
12. e the date entered in next due date VFM Due Date Date that the computer automatically calculates for the next vaccine s that are due Refresh Button Click the refresh button after any shots new or historical have been entered so that that the VFM is saved based on the most recently updated information Bottom Of Immunization Screen Print Button Click this to print the patient s Immunization Report Print to California Immunization Record CIR Button Click this to print the patient s California Immunization Record commonly known as the yellow card Historical information refers to immunizations given by other providers or shots that did not come out of inventory Vaccine Check in the blank box next to the name of the appropriate vaccine Vaccine date Use General Rules for dates to enter the month date and year For transcribing immunization records from Mexico please note that the day is written first then month then year You must reverse the month and date for SDIR _ Vaccinator Enter name from drop down list if relevant Leave blank if unknown Body Site Select the appropriate body site if documented on the medical record or CIR Select unknown if not known Other Check the other box for vaccines that are historical and that were given by another provider Page 10 7 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES Common errors
13. ect the state in which the patient was born CA California will be selected for birth records e Mother s Last Current last name of mother Maiden name is okay only if it is her current last name Follow General Rules for names e Mother s First Current first name of mother Follow General Rules for names e Mother s Middle Middle name of mother Follow General Rules for names e DOB Date of Birth of mother Follow General Rules for dates e SSN Mother s social security number e Maiden Name Mother s maiden name Follow General Rules for names e Med Record The medical record of the patient e Facility Name of Provider facility site e Confidential Drop down box to indicate if the patient parent does not want the file to be shared e Reminder Drop down box to indicate yes or no as to whether the patient parent wants a reminder notice sent for shots due Default setting is yes e Status Drop down box to indicate whether the patient is active or inactive with that provider or is deceased e VFC Drop down box to indicate the patient s status in terms of the Vaccines for Children VFC program Choices are 1 CHDP Medi Cal 2 No Private Insurance 3 American Indian Alaskan Native 4 Insurance does not pay 5 not qualified Default setting is S not qualified It is very important for VFC providers to verify and enter the current VFC status of the patient
14. eminder notices sent or are overdue or missing immuniza tions The report has a variety of different choices to select from by provider facility next due date date of birth as well as a sorting feature by due date date of birth last first names or medical record number 2 Activity Report Reminder and recall reports can be generated using the activity report feature The age of children in months activity date s report type and pro vider facility may be selected to create this sorted list c Quarterly Activity Report This report is used by public health centers and community clinics which receive state funds for conducting immunization clinics for children under 4 years of age to submit to the County Immunization Branch a summary of certain activi ties related to the population they served and their immunization follow up activities such as reminder recall The report summarizes reminder recalls sent out and immunizations including a specific breakout of MMR doses given to children under 4 d Provider Profile This report looks at the following data quality and improvement criteria Number of duplicate home records reminder recalls sent expired lots VFC Not Quali fied patients private non VFC lots number of patients with no address bad address and no phone bad phone numbers Export for CASA and COCASA A report for CASA or COCASA can be generated by a provider site for children of specified birth date ranges
15. ge any of them These are based on your facility inventory Go to the Administration Tab to add or update inventory Body Site Choose a body site from the drop down box Choices are LL SQ left leg subcutaneous RL SQ right leg subcutaneous LA SQ left arm subcutaneous RA SQ right arm subcutaneous Lat IM left anterolateral thigh intra muscular RAT IM right anterolateral thigh intra muscular Page 10 6 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES LD IM left deltoid intra muscular RD IM right deltoid intra muscular Oral should only be used for historical records since no vaccines are given orally in the U S Unknown should only be used for historical records Vaccinator A drop down box will appear with the choices of vaccinator Click on the appropriate name e Show forecast for next due date This text will appear in the vaccine forecast box when the individual is current up to date and no vaccines are due Clicking on the text will change the date in the vaccine forecast and show the optimum time to bring the patient and what vaccines will be needed Next Due Date The next due date will be the automatically be populated with the VFM due date The user can manually add a return due date for the patient if it is different than the next due date You must highlight and delete the entire date to enter in another date Update Button Click on the update button to sav
16. n mother father emancipated minor emergency contact aunt brother grandfather grandmother sister uncle neighbor other relationship other relative Guardian 2 Last Secondary guardian s last name Follow General Rules for Names Guardian 2 First Secondary guardian s first name Follow General Rules for Names Guardian 2 Middle Secondary guardian s middle name Follow General Rules for Names DOB Secondary guardian s date of birth Follow General Rules for Dates SSN Secondary guardian s social security number Guardian 2 Relationship Secondary guardian s relationship to patient Drop down box Choices are self unknown guardian mother father emancipated minor emergency contact aunt brother grandfather grandmother sister uncle neighbor other relationship other relative Medi Cal The Medi Cal number of the patient Email Address The email address of the patient parent Email POC Email Point of Contact Another email address where the patient parent can be reached Email Bad Drop down box with two choices email returned wrong address or email sent no response Phone 3 Place to enter a third phone number to contact patient parents Contact 3 Drop down box of choices relating how to contact patient parents if main phone number is not useful Choices are home pager mother pager father cell mother cell father work mother work father relative
17. nt and general Patient update screens Patient Alias Last Another last name by which the patient is known Follow General Rules for Names Patient Alias First Another first name by which the patient is known Follow General Rules for names Patient Alias Middle Another middle name by which the patient is known Follow General Rules for names Patient SSN The patient s social security number Ethnicity Ethnicity of patient Drop down box Choices are American Indian Alaskan Native Asian Pacific Islander Black African American White Hispanic Other Unknown Filipino Eskimo Aleut Language Primary language spoken by patient Drop down box Choices are Arabic Cambodian Chinese Cantonese Chinese Mandarin English Farsi Hmong Japanese Korean Laotian Russian Serbian Somali Spanish Tagalog Vietnamese Other Guardian 1 Last Primary guardian s last name Follow General Rules for Names Guardian 1 First Primary guardian s first name Follow General Rules for Names Guardian 1 Middle Primary guardian s middle name Follow General Rules for Names DOB Primary guardian s date of birth Follow General Rules for Dates SSN Primary guardian s social security number Page 10 4 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES Guardian 1 Relationship primary guardian s relationship with patient Drop down box Choices are self unknown guardia
18. ntraindications are conditions in an individual that greatly increases the chance of a serious adverse reaction In general vaccines should not be given when a contraindication is present Precautions are a condition in a recipient that greatly in creases the chance of a serious adverse reaction or compromise the ability of the vaccine to pro duce immunity In general vaccines are deferred when a precaution is present however the benefit of having the vaccine may outweigh the risk of an adverse reaction Epidemiology and Prevention of Vaccine Preventable Diseases 9th Edition Jan 2006 pgs 1 17 Page 10 8 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES TB TAB Originally this section was developed for providers participating in the Community Action Plan to Prevent Tuberculosis CAPP TB program in San Diego County However currently any providers may use the test area to enter TB test information only The first five rows of the CAPP TB screen are pre filled with patient information from the main demographic record Risk factor By clicking on the words Risk Factor you will open a screen that says Latent TB Module Risk Factors Click in the appropriate box es and then click the update button Test Click Test to open the Latent TB module TB test screen Click on words add new TB test to add new test information TB Program Subscriber This information is obsolete Tre
19. r 1 1 02 type 01012002 Most dates cannot be less than patient birth date or greater than current date Numbers Only numbers are allowed in the numbers field Social Security Number SSN Although SSN are not required or recommended to be in the registry if desired the 9 digits can be entered with or without hyphens Addresses The address information is used when mailing reminder recall postcards Therefore it is important that the data entered will print as a deliverable address Enter apartment and suite numbers on the 2naline You may use abbreviations acceptable to the US Post Office For more information go to http www usps gov ncsc lookups abbr_suffix txt Page 10 1 12 09 Your Guide to SDIR SECTION 10 DATA ENTRY GUIDELINES The following is a list of common address abbreviations AVENUE AVE COURT CT PLACE PL BOULEVARD BLVD DRIVE DR ROAD RD CANYON CYN HIGHWAY HWY STREET ST CENTER CTR LANE LN VALLEY VLY CIRCLE CIR PARKWAY PKWY VIEW VW Address 2naline Usually used for apartment or suite numbers Do not enter more than one deliverable address e g do not enter a street address in Line 1 and a P O Box in Line 2 City Type the correct city Zip Code Enter 5 digit or 9 digit zip code separated by a hyphen Phone Phone numbers should be 10 digits including area code entered with or without hyphens THE REMAINDER OF THIS DOCUMENT IS SEPARATED INTO THE VARIOUS TABS AND
20. to decide if you want to view unique records includes valid and invalid immunizations and booster doses valid immunizations only or all immunizations given includes duplicate immunizations immunizations given too early etc Disease History Click on words disease history Choose add new A drop down box will appear with choice of Chickenpox along with a comment section Vaccine Forecast Auto populated with the vaccines due at the current visit Add from Inventory or List Click on Inventory and a new box will appear with the following fields Vaccine Choose the appropriate vaccines Also consult section on Common Vaccination Errors If a combination vaccine was given that contained two or more vaccines e g DTaP HIB Comvax or DTaP Hep B IPV Pediarix enter these particular combos in the correct area of the vaccines Combo vaccines will be automatically calculated in the appropriate vaccine families on the California Immunization Record CIR Date Date is auto populated by the computer s date but may be manually overridden Follow General Rule for Dates if today s date is not correct Note Dates that do not include a month or a year are invalid Do not record any immunizations without both a month and a year If the date day is not known use 01 5 2000 should be 05 01 2000 Dose Dose number is auto populated Lot Manufacturer VIS Date All are auto populated Do not chan
21. when giving vaccinations and or entering vaccination information into the SDIR Combination Vaccines example DTaP and Hib Sometimes these are administered separately or as a DTaP Hib combination vaccine Be sure to enter these as the appropriate combination vaccine DTP Sometimes DTP is chosen instead of DTaP DTP is no longer generally used in the U S but is still available in some foreign countries This should only be used for historical vaccines given by other providers OPV Oral polio vaccine This should only be used for historical vaccines given by other providers OPV is no longer used in the U S but is common in historical records Pneumo This should only be used for historical vaccines given by other providers If entering an administered vaccine select the specific type of Pneumococcal vaccine either PCV 7 or PPV23 Body Site Select the appropriate body site if known Select unknown if not known Other Check Other if the vaccine was given by another provider Insert button You must click on the insert button after every vaccine given on a different date Cancel button Click on the cancel button to return to the Immunization screen The list of Contraindications and Precautions is in the same field however they can and many times are separate health issues They can also be conditions which are permanent or temporary Tem porary conditions can be given a start and end date Co
22. where patient resides Follow General Rules for addresses e State State where the patient resides Select Other for Mexico or other states outside the US Follow General Rules for addresses e Zip Zip code of patient s residence Follow General Rules for addresses e Bad address Drop down box gives you a choice of entries based on information from the returned mail unclaimed refused unknown address insufficient address invalid street no moved no address returned for postage no address e Phone I Residential phone number of patient parent e Contact 1 Drop down box of choices relating how to contact patient parent if main phone number is not useful Choices are home pager mother pager father cell mother cell father work mother work father relative bad phone bad area code e Phone 2 Phone number of Contact 2 e Contact 2 Drop down box of choices relating how to contact patient parent if main phone number is not useful Choices are home pager mother pager father cell mother cell father work mother work father relative bad phone bad area code e Multiple Births This is important when considering whether two or more records are duplicative There is a drop down box to choose if the child was a Single Twin 1 Twin 2 Triplet 1 Triplet 2 Triplet 3 Quadruplet 1 Quadruplet 2 Quadruplet 3 Quadruplet 4 Multiple 1 9 Default setting is Single e Birth State Sel
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