Record the number of patients for each category below for the month being reviewed.
|
*Facility ID# :
|
*Vaccination type: Influenza
| *Month:
| *Year:
|
Patient categories
| Number of patients in each category
|
*1. Total # of patient admissions
| |
| |
*2. Total # of patients meeting high risk criteria for influenza vaccination
| |
3. Total # of patients previously vaccinated during current influenza season
| |
*4. Total # of patients meeting high risk criteria previously vaccinated during current influenza season
| |
*5. Total high risk patients not previously vaccinated during current influenza season (Denominator: Box 2 - Box 4)
| |
| |
*6. Patients meeting high risk criteria offered vaccination but declining for reasons other than medical contraindication.
| |
*7. Patients meeting high risk criteria offered vaccination but having medical contraindication
| |
*8. Patients meeting high risk criteria receiving vaccination during admission
| |
*9. Total patients offered vaccination for high risk criteria (Numerator: Box 6 + Box 7 + Box 8)
| |