Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Vaccination (specify vaccine type)
Follow-up after vaccination – evaluation of injection site pain
History of Present Illness:
Date of vaccination.
Type of vaccine administered.
Description of injection site pain:
Onset (immediately after, hours later)
Severity (mild, moderate, severe)
Character (sharp, throbbing, aching)
Any associated redness, swelling, or warmth at the injection site
Past Medical History:
History of fainting or allergic reactions after previous vaccinations.
Any underlying medical conditions (consider conditions that might
increase pain sensitivity).
Current medications (some medications may interact with vaccines and
cause increased pain).
Social History:
Anxiety about needles or vaccinations (may contribute to pain perception).
Physical Examination:
General examination: Assess vital signs for any signs of infection
(fever).
Focused examination of the injection site: Look for redness, swelling,
or warmth. Palpate for tenderness.
Assessment:
Pain at injection site: Based on the patient’s description and
physical examination findings.
Severity of pain: Consider the impact of pain on daily activities
and patient’s self-reported level of discomfort.
Possible causes of pain: Consider needle size, injection technique,
and individual pain sensitivity.
Plan:
Management of injection site pain:
Recommend over-the-counter pain relievers (e.g., acetaminophen,
ibuprofen)
unless contraindicated.
Apply cool compress to the injection site for short periods
throughout the day.
Reassurance and education on expected side effects and their
duration.
Documentation: Document the type of pain medication recommended
and dosage instructions.
Follow-up:
Advise the patient to contact the clinic if the pain worsens, persists
for more than a few days, or if they develop any other concerning symptoms
(e.g., fever, redness that spreads).
Additional Notes:
Consider offering topical anesthetics (lidocaine cream) for future
vaccinations if the patient experiences significant pain and desires
it.
Document any interventions or education provided to address anxiety
about vaccinations.