2 Processes for safe immunisation

2.9 Documentation and insurance

2.9.1 Documentation and record keeping

Accurate documentation (including information on the NIR and SBVS) is essential. If the vaccinator has not kept accurate clinical records, it is difficult to prove what action/care was or was not taken/delivered if the patient notes are subject to legal scrutiny.

In addition to the information recorded on the NIR or SBVS, information that should be collected in the patient’s clinical notes includes:

The vaccinator should also complete the relevant sections in the Well Child Tamariki Ora My Health Book, and, where applicable, the child’s Immunisation Certificate (see Appendix 5), the Ministry of Health payment claim form (where applicable), and an NIR notification form if not using a computerised patient management system.

2.9.2 Indemnity insuranceTop

All vaccinators should carry indemnity insurance. Most employers have indemnity cover, but vaccinators do not have an automatic right to claim under that cover. Indemnity insurance should cover vaccinators/health professionals for disciplinary proceedings, coroners’ inquiries, and claims of negligence or error that may lead to injury, death or damage.