How should I assess the immunisation status of an adult patient presenting for a routine check-up?

Assessing the immunisation status of an adult patient during a routine check-up involves the following steps:

• Check the patient's vaccination records using available sources such as the NHS summary care record, electronic medical records, or any patient-held vaccination records. If the patient does not have a documented or reliable verbal vaccine history, assume they are not immunised and plan a full course of immunisations accordingly.
• Use electronic health record templates with relevant SNOMED CT codes to accurately record vaccination status and any vaccinations given.
• Ask the patient about any vaccinations received outside the UK or in other healthcare settings to clarify their immunisation history, especially for those born abroad.
• Use prompts and reminders in the clinical system to opportunistically identify and offer any vaccinations the patient is eligible for or overdue.
• If the patient’s immunisation history is uncertain or incomplete, follow the UKHSA guidance on vaccination of individuals with uncertain or incomplete immunisation status, which generally recommends completing or resuming vaccination courses rather than restarting them.
• Ensure that any vaccinations given are recorded promptly and accurately, including consent details, vaccine batch, date, and site of administration.

This approach ensures a comprehensive assessment and appropriate catch-up vaccination if needed, supporting protection against vaccine-preventable diseases in adults.

References: NICE NG218, NICE CKS