Documentation requirements for nurses working in medical centres providing immunisations

There have recently been lots concerns surroundingholding a Nurse Immuniser credential) These nurses
the issue of documentation requirements relating tomay initiate immunisations as long as the vaccine is
immunisation. The recent spike in Medicare auditspart of the current vaccination schedule (cannot
focusing on adequate documentation andinitiate travel vaccinations).
circumstances surrounding nurse MBS items (10993)- Immunisation Providers can give immunisation
have made this an even more popular topic. Below iswithout the need of a doctor in the building.
a breakdown of essential do's and don'ts depending- The nurse initiates vaccination from the schedule
on the qualifications of the nurse administering thefor the patient and administers the same.
vaccination Registered Nurses Division 1 and Endorsed- The Nurse documents encounter
ENs (not credentialed Immunisation Providers) These- Claim item 10993 (under the patient's usual provider)
nurses must only give medications and vaccinationsand 10990 if applicable.
following a written order by the General Practitioner.- When routine immunisations are being provided by
Meaning the GP must see the patient and add hiscredentialed nurse immunisers, there is no need for
own entry in the patient file as to what will bethe patient to see a medical practitioner, therefore,
administered. (Medicare item 3 or 23). Theno other professional consultation item (e.g. 3, 23, 36)
practicenurse may then administer the immunisationshould be claimed by the GP unless a separate
(item 10993). The General Practitioner must be in theservice not related to immunisation was also required.
building for the duration of the immunisation as wellWhenever a professional attendance item is claimed
as for 15 minutes after just in case of an(3, 23, 36, etc), there has to be written evidence of
anaphylactic event. The nurse must then make anthe particulars of the consultation (an entry in the
entry in the patient record detailing whatpatient file) made by the doctor claiming the item.
immunisation was administered, and site of injection.Also note that nurse-related Medicare items only
If the service is to be bulk billed and the patient isapply to nurses holding a current registration with the
under 16 years of age or a commonwealthnurses board in the state of Victoria. These items
concession card holder then item 10990 can also bemust not be claimed by nurses not yet registered,
billed Immunisation Providers (RN Div 1 currentlymedical students or other practice staff.