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
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| | |
*2. Total # of patients meeting high risk criteria for influenza vaccination
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3. Total # of patients previously vaccinated during current influenza season
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*4. Total # of patients meeting high risk criteria previously vaccinated during current influenza season
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*5. Total high risk patients not previously vaccinated during current influenza season (Denominator: Box 2 - Box 4)
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| | |
*6. Patients meeting high risk criteria offered vaccination but declining for reasons other than medical contraindication.
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*7. Patients meeting high risk criteria offered vaccination but having medical contraindication
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*8. Patients meeting high risk criteria receiving vaccination during admission
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*9. Total patients offered vaccination for high risk criteria (Numerator: Box 6 + Box 7 + Box 8)
| |
