Patient Screening and Documentation
Core concepts
Screening prevents harm. Before any dose, obtain a history of allergies (especially to vaccine components such as gelatin, yeast, or latex), prior adverse reactions, current illness, pregnancy status, immunosuppression, and bleeding disorders. Know contraindications versus precautions: a contraindication means do not give the vaccine (e.g., severe allergic reaction to a prior dose or component); a precaution means weigh risks and benefits and may defer.
Live vaccines generally are contraindicated in pregnancy and in significantly immunocompromised patients. Egg allergy is no longer a blanket contraindication for most influenza vaccines; screening guidance has evolved, so follow current labeling. Document the vaccine name, lot number, expiration, site, route, dose, date, administrator, and the patient's consent and VIS (vaccine information statement) provision.
Traps
Questions blur contraindication and precaution, or imply all egg-allergic patients cannot receive flu vaccine. Another trap: forgetting to document the VIS date, or documenting only the vaccine name without lot and site. Watch for questions that treat mild acute illness as an automatic deferral - mild illness with or without low-grade fever is generally not a reason to postpone.
Worked example / rule of thumb
Rule: "Screen, consent, then stick." If a patient reports a severe reaction to a prior dose of the same vaccine, that is a contraindication - do not administer; document and refer.