SOAPware DocumentationClinical EMR Training ManualsClinical User Manual ImmunizationsEntering Historical, Refused or Not Performed Immunizations

Entering Historical, Refused or Not Performed Immunizations

To create a complete immunization record that includes historical, refused or not performed immunizations, immunizations can also be entered directly from the Immunization chart section.

When a new historical, refused or not performed immunization is recorded for a patient, it will automatically be transferred to the SOAPnote Subjective section.

Open the Immunization Chart Section

To record that an immunization was refused, not performed or is part of the historical record, open the Immunization chart section.

Record the Immunization

Record the Immunization

Click the Add Immunization button (green + button). The Add Immunization window will appear.

Select Immunization

Select Immunization

Select the immunization that you wish to record by following the steps below:

  1. Search: Search for the immunization by typing the name into the Search box, then click the Find button.
  2. Select: Highlight the immunization from the search results.
  3. Edit: Complete the desired sub-items (the SMARText Quick Access window must be visible). Ensure you complete the Status sub-item to record the correct status as either historical, not performed or refused.
  4. Add: Click the Add button to record the immunization.

Immunization Recorded

The immunization will be recorded in the Not Performed section of the Immunizations chart section.  In addition, when the  immunization has a Refused Status selected, the immunization will be recorded in the active SOAPnote Subjective section to document that the immunization was not performed.