Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons)
HCPCS code
Name of the Procedure:
Influenza Immunization Not Administered Due to Clinician-Documented Reasons
Common Name(s): Flu Shot Not Given
Technical/Medical Term: HCPCS Procedure Code G8483
Summary
This procedure refers to instances when the flu vaccine is not administered to a patient due to documented reasons by a healthcare provider. This can include medical issues like allergies, the unavailability of the vaccine, or patient refusal.
Purpose
This documentation is used to explain why a standard influenza vaccine was not provided to a patient. It ensures clarity in medical records and helps in understanding the barriers to vaccination.
Indications
- History of severe allergic reactions to the flu vaccine.
- Current medical condition where the flu shot is contraindicated.
- Patient decision to decline the vaccine.
- Temporary unavailability of the vaccine in the healthcare facility.
Preparation
No specific preparation is needed for this documentation process. However, a thorough medical history review and patient consultation should be conducted.
Procedure Description
- Assessment: The healthcare provider assesses the patient's medical history and current condition.
- Discussion: The provider discusses the flu vaccine with the patient, explaining the importance and addressing any concerns.
- Documentation: If the vaccine is not administered, the provider documents the reasons in the patient’s medical records. This includes any medical contraindications, patient decisions, or systemic issues like vaccine shortages.
- Follow-Up: If appropriate, the provider may recommend alternative preventive measures or schedule a follow-up for vaccination if circumstances change.
Duration
The documentation process typically takes about 5-10 minutes.
Setting
This procedure is performed in various settings including hospitals, outpatient clinics, and private medical offices.
Personnel
- Licensed Nurses
- Primary Care Physicians
- Physician Assistants
- Medical Assistants
Risks and Complications
There are no direct medical risks or complications associated with this documentation procedure itself. However, not receiving the influenza vaccine can result in increased risk of contracting the flu and its associated complications.
Benefits
Ensures accurate medical records and helps identify barriers to vaccination, which can inform future patient care and public health strategies.
Recovery
No recovery is needed for the documentation process. The healthcare provider might offer alternative advice such as increased hygiene practices to prevent influenza.
Alternatives
- Reassessment at a later date to determine if the vaccine can be administered.
- Alternative forms of immunization if available and applicable.
- Increased reliance on general protective measures like hand hygiene and avoiding crowded places.
Patient Experience
Patients might experience a discussion regarding the importance and safety of the flu vaccine. They may receive advice on alternative health measures or reassessment plans if the vaccine is temporarily unavailable. Pain or discomfort is not involved in the documentation process itself.