Sample Admission Checklist for Determination of ...
Admission Checklist
Influenza and Pneumococcal Immunization*
|Resident: |Room#: |
|Assessed by: |Date: |
|Influenza Vaccine (given October – May) |Pneumococcal Vaccine (offered year round) |
|Considered high risk due to: |Recommended intervals for healthy* adults ≥65 years of age: |
|Every long-term care resident is at risk for influenza infection and|Begin the adult pneumococcal series with PCV13 whenever possible. |
|possible pneumonia infection. |Interval spacing between any PCV13 and PPSV23 dose is ≥1 year, |
|◊High-risk: |regardless of which dose is given first. |
|Immunocompetent: Chronic heart disease, Chronic lung disease, |If either PCV13 or PPSV23 is inadvertently given less than 12 months |
|Diabetes Mellitus, CSF leaks, Cochlear implants, Alcoholism, Chronic|apart, do not repeat either dose. |
|liver disease, Cigarette smoking, Asthma, |PCV13 and PPSV23 cannot be given at the same visit. |
|Those living in residential care centers. |Recommended interval for high-risk◊ persons ≥65 years: |
| |Recommended intervals for high-risk◊ persons |
|Immunocompromised: Sickle cell disease or other hemoglobinopathies, |19–64: ≥8 weeks from PCV13 to PPSV23 |
|Congenital or acquired asplenia, Congenital or acquired |19–64: ≥1 year from PPSV23 to PCV13 |
|immunodeficiencies, HIV infection, Chronic renal failure, Nephrotic |2–18: 8-week interval spacing between PPSV23 and PCV13, regardless of |
|syndrome, Leukemia, Lymphoma, Hodgkin disease, Generalized |which was given first |
|malignancy, Iatrogenic immunosuppression (including | ................
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