Vaccines & Other Services
Providers will order vaccines, EKGs, ear lavages & other services for patients.
Sometimes patients will come in for an MA appointment without seeing a
provider. It is important to properly document these accurately in the patient's
chart & in your daily Vaccine Log. Here’s a guide of common services & how to
document them.
Vaccines:
● The provider will clip the requested vaccine card to exam room door
● Before administering a vaccine, double check the patient’s chart (PMH and
‘Immunization’ tab) to make sure they haven’t already received it
● Make sure the correct vaccine has been circled on the superbill
● After the vaccine is administered, document the patient name, DOB,
vaccine name, LOT #/EXP date, and injection site on your Vaccine Log
● Document the vaccine given and today’s date in the PMH > Preventive
Care section
● Also document the vaccine details in the Immunizations tab
Paps:
● Performed by provider, you must document in Vaccine Log
● Make sure the patient’s name, DOB, & the DOS is written on the specimen
bottle. Lab order should be test order #: “199305 - IGP, Aptima HPV, rfx
16/18, 45”. Please double check all labels to make sure everything is
correct. Lab will not accept mislabelled specimens!
UA Dip Test:
● Set up test supplies on top of the fridge in the restroom. You will need:
urine collection cup with patient’s initials, sanitary swipe
● After patient leaves specimen, take to lab & perform dip test. Record
findings on the UA form
● Record in Vaccine Log & present to provider. Use urine straw to transfer
specimen into UA & culture tubes. Confirm lab order & specimen tubes are
properly labeled
EKGs:
● The provider will clip the requested vaccine card to exam room door
Vaccines & Other Services
● Check with the patient before entering the room with the EKG table. Make
sure they are properly dressed for the procedure - they should have
undressed from the waist up and put on a gown with the opening in the
front
● Bring in the EKG table & use alcohol swabs to wipe down the areas where
you will be placing the tab electrodes. If a patient has lotion or oily skin the
tabs will not properly stick. (See placement guide for where to place tabs)
● Attach corresponding electrodes to limbs - RL, LL then RA LA, then V1
through V6
● Patient should be fully relaxed with arms flat by their sides. Plug in the
machine allow & a couple of seconds to boot up
● Make sure that the screen reflects the patient’s sex. No need to change the
age. Press “start” & the machine will print out the report
● DO NOT INTERPRET RESULTS TO PATIENT. Tell the patient that you
will have the provider check. In the meantime, they can get dressed and
wait for the results
● Mount the report paper & write the patient's name, DOB & your initials.
Make a copy of the report - sometimes these can go missing! Save the copy
at your desk just in case
● Provider will review & sign. You can inform the patient if normal, usually if
abnormal the provider will discuss. File the report for scanning &
document in Vaccine Log & if needed for pre-op clearance:
○ Attach report along with chart notes, lab results, and pre-op
paperwork if possible
○ Fax to surgeon's office with cover sheet - include patient’s name,
DOB, surgeon’s name or group
○ Create an “Orders Only” encounter to document that you have faxed
the paperwork and you’re done!
Ear Lavages:
● Check ears for wax. If ordered by provider, they will usually specify which
ear needs washing
● Fill bottle with warm water, check with your pinky to make sure it’s not too
hot. It’s important that the water is warm that way it loosens the wax.
● Have the patient hold the water basin with their opposite hand. Make sure
to have paper towels handy. Perform ear lavage
Vaccines & Other Services
● Document in the patient’s chart & in Vaccine Log. You can copy/paste this
template for the chart and change as needed:
# BILATERAL IMPACTED CERUMEN -- EAR LAVAGE PERFORMED:
- LARGE AMOUNT OF CERUMEN RETURNED FROM L EAR CANAL
- SMALL AMOUNT OF CERUMEN RETURNED FROM R EAR CANAL
- BILATERAL EAR CANALS CLEAR POST LAVAGE
● If unsuccessful, recommend the patient use Debrox earwax to loosen
better. They can return after a few days for another lavage if needed
TB/PPD Test:
● This is usually an appointment with the MA’s only. Usually needed for
clearance for a job or school
● Patient can only schedule TB test on Monday, Tuesday, or Wednesday as
they will need to return in 2 days for reading
● Create a “Nurse visit” encounter, “Medical Assistant Visit” note type &
document. Prep paperwork for patient. You can find it in the Drive if
needed
● Patient will return in 2 days for reading. Complete paperwork, make a copy
& file for scanning, give patient original & complete encounter note
● Pssst ;) patients can also get TB clearance as a lab! Order blood work LabCorp test#: 182879 - QuantiFERON-TB Gold Plus