19 Jan 2016

Record keeping and consent

Guidelines for best practice in record keeping for health professionals working at the YFVC Record keeping and consent

Guidelines for best practice in record keeping should be followed by all health professionals working at the YFVC [1-5]. NaTHNaCs Code of Practice requires that the designated YFVC must have systems in place to ensure records of vaccination for adults and children will be maintained and archived or disposed of in accordance with the Records Management Code of Practice for Health and Social Care 2016 [6]. YFVC should be aware that, due to lifelong validity, duplicate certificates can now be requested many years after vaccination but can only be issued where a satisfactory record exists.

Where the person to be vaccinated at the YFVC is a registered patient of that centre, a record of YF risk assessment and vaccine administration should be made in the patient’s medical record. Persons attending the centre who are not registered patients at that centre should have a personal record constructed that should be retained by the centre.

Medical records kept at the YFVC should be sufficient to enable a health professional to re-issue an International Certificate of Vaccination or Prophylaxis (ICVP) in the future. Consent of the person to be vaccinated, should be obtained according to national guidance [7]. Risks and warnings given to the person with regard to the vaccination should be documented in the clinical record.

Records can be maintained in paper or electronic copy. YFVCs that operate a paperless system should ensure that they are able to produce these details for inspection or reference at short notice if appropriate [6].

Individuals who have received YF vaccine must be issued with an ICVP. They should be advised to store it in a safe place, usually with their passport and be encouraged to make a photocopy, kept separately, which would be of assistance should re-issue of a mislaid ICVP become necessary.

If, at any stage, the centre ceases to remain a YFVC, arrangements must be made to keep the records either at that centre, or be transferred to another centre. In the event of the closure of a YFVC, records pertaining to YF vaccine must be archived according to the Data Protection Act 1998 [8] and local guidelines. NaTHNaC must be informed of the change [9].

  1. Department of Health (2009) Records management: NHS code of practice, part 2, 2nd Edition 2009; London, Department of Health.
  2. The Scottish Government (2008) Records management: NHS code of practice, 2012; (Scotland) Edinburgh, The Scottish Government.
  3. National Assembly for Wales (2000) Welsh Health Circular (2000) 71 Cardiff, National Assembly for Wales.
  4. Department of Health, Social Services and Public Safety, Northern Ireland (2005) Good management, good records Belfast, Department of Health, Social Services and Public Safety, Northern Ireland.
  5. Nursing and Midwifery Council. The Code: Professional Standards of practice and behaviour for nurses and midwives. 29 January, 2015. [Accessed August 2015]
  6. NaTHNaC, Yellow fever Vaccination Centre, Code of Practice 2016
  7. Public Health England, Consent. Ch 2. In. Immunisation against infectious disease, March 2013. [Accessed February 2016]
  8. Data protection Act 1998.
  9. National Travel Health Network and Centre. Conditions of Designation 2016

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