include poorly controlled diabetes mellitus, hematologic malignancies presentations are in patients with diabetes who have ketoacidosis and who tend …
SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
DIVISION OF INPATIENT SERVICES DIS
PATIENT IMMUNIZATION ASSESSMENT AND
LICENSED PRESCRIBING PRACTITIONER LPP ORDER FORM
| | | |
|PNEUMOCOCCAL PNEUMONIA IMMUNIZATION |INFLUENZA IMMUNIZATION |
|Risk Assessment: Patient is at high risk|Risk Assessment: Patient is at high risk|
|due to: |due to: |
| |Age 65 or older | |Age 50 or older |
| |Age less than 65 and history of heart | |Age less than 50 and history of heart |
| |disease, lung | |disease, lung disease, end stage renal|
| |disease, end stage renal disease, | |disease, weakened immune system, |
| |weakened immune system, diabetes, | |diabetes, seizure disorder, cognitive |
| |non-functioning or absent spleen, or | |dysfunction, spinal cord injury or |
| |other chronic medical conditions | |other chronic medical conditions |
| |None of the
above listed STOP | |None of the above listed STOP |
| |Proceed to Influenza | |Proceed to LPP Order |
|Contraindications: Vaccine not indicated |Contraindications: Vaccine not indicated |
|due to: |due to: |
| |Previously immunized for pneumococcal | |Previously immunized for influenza |
| |pneumonia | |during this |
| | | |flu season September 1 - May 1/CDC |
| | | |Rec |
| |Hypersensitivity to the vaccine | |Allergic to eggs or thimerosal |
| |Previous adverse reaction to pneumonia | |Previous adverse reaction to influenza|
| |vaccine | |vaccine |
| |Febrile respiratory illness or active | |Acute febrile illness |
| |infection | | |
|Outcome: |Outcome: |
|
|Vaccine indicated | |Vaccine indicated |
| |Vaccine indicated but patient declined| |Vaccine indicated but patient |
| | | |declined |
| |Vaccine contraindicated | |Vaccine contraindicated |
| |Patient/Family educated on risks versus| |Patient/Family educated on risks |
| |benefits of | |versus benefits of |
| |vaccination | |vaccination |
|LPP Assessment Signature: |Date: |Time: |
| | | |AM |
| | | |PM |
|LPP Order: |LPP Order: |
| |Administer Pneumococcal Vaccine | |Administer Influenza Vaccine |
| |05 mL IM | |05 mL IM |
| | | |
|
| | | | |
|LPP Order Signature: |Date: |Time: |LPP Order Signature: |Date: |Time: |
| | | |
| | | |
|Date: |Time: |Date: |Time: |Date: |Time: |
| | |
