Date
Patient: [Patient Name], [MRN]
Reason for Visit: Pneumococcal vaccination
History
Age and immunocompetence (important for vaccine selection)
Underlying medical conditions (e.g., chronic lung disease, heart disease, diabetes) – increases risk of pneumococcal complications
Previous pneumococcal vaccination history (type of vaccine, date) – influences vaccine selection and frequency
Smoking history (increases risk of pneumococcal complications)
Allergies (particularly to eggs or thimerosal)
Physical Exam
Vital signs (temperature, heart rate, blood pressure) – performed routinely
Assessment
Indication for pneumococcal vaccination based on current guidelines (consider age, risk factors, and previous vaccination history)
Choice of pneumococcal vaccine:
PCV13 (Prevnar 13): Protects against 13 serotypes of Streptococcus pneumoniae
PPSV23 (Pneumovax 23): Protects against 23 serotypes of Streptococcus pneumoniae
Selection may depend on age, underlying conditions, and previous vaccination history
Plan
Administered pneumococcal vaccine: [Vaccine name], [dose] (intramuscular)
Discussed potential side effects:
Pain, redness, or swelling at the injection site
Low-grade fever, fatigue, muscle aches (usually mild and resolve within 1-2 days)
Advised patient to report any severe or persistent side effects to the healthcare provider.
Education
Explained the benefits of pneumococcal vaccination in preventing serious infections like pneumonia, meningitis, and sepsis.
Discussed the importance of completing the recommended vaccination schedule (if applicable).
Provided resources for further information on pneumococcal disease and vaccination (optional).
Follow-up
No specific follow-up needed unless the patient experiences concerning side effects.
Documented the vaccination in the patient’s medical record.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for specific recommendations regarding pneumococcal vaccination in adults.