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

1. Click on the Chart Navigator docked tab.
2. Double-click on the Immunizations chart section.

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

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.

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