Inland Empire Region CAIR v 3.30 Data Entry Guide Rev 4/09 Riverside County Department of Public Health A partnership between San Bernardino County Department of Public Health Help Desk 1-866-434-8774 phone 951-358-3403 - fax Website http://cair-ie.cairweb.org
Table of Contents Table of Contents Section 1 Introduction to CAIR What is CAIR...1 Patient Disclosure...1 Refusal to participate...2 Section 2 Welcome to the Registry Logging into the CAIR...3 Changing your user password...4 Entering a challenge phrase...4 Section 3 Data Entry Functions Searching for a Patient...5 Updating an Existing Record...7 Entering a New Patient...8 Entering Additional Information...9 Entering Historical Shots...11 Entering New Shots...12 Special Functions...13 Waivers Notes Adverse Reactions Risks Had Chicken Pox Patient Reports...14 Official Immunization Record Detailed Immunization Report Routing Slip Data Entry Guidelines...16
Sample CAIR Disclosure Statement Section 1 Introduction to CAIR s What is CAIR? The California Immunization Registry (CAIR) is the statewide registry in California. CAIR is a secure Internet-based system used by providers and other approved agencies to track immunizations of their patients and to improve their immunization services. Don t know what to say to a new patient? Try this: CAIR is a secured database that is used in our office to help keep track of your child s immunizations. It helps children get their shots on time. Patient disclosure Per California Health and Safety Code (Section 120440), all patients must receive a CAIR Disclosure Statement before any of their or their child s information can be entered into the Registry. As a CAIR user, you must: Provide a CAIR Disclosure Statement and CAIR Parent FAQ to each patient whose information will be entered into CAIR. Disclose to the parent or legal guardian if the patient is under the age of 18. Ensure that the patient understands the information in the CAIR Disclosure Statement and has the opportunity to ask questions if he/she is unclear about it. Document in the Registry that the patient has been disclosed by selecting Yes to the questions on the Preferences screen in CAIR. Has patient been disclosed? and Has patient agreed to share? Remember, disclosure only needs to be done once, and should be in the patient s preferred language. Disclosures in additional languages can be obtained from the Help Desk or downloaded from our website. 1
Welcome to the Registry Section 1 Sample Decline of Start Sharing Information Request Form Refusal to participate The information of a patient who has refused to participate will still be entered into the registry, however the record will be locked. The provider who entered the information can view the data but others may not. A patient or parent/guardian may refuse participation at any time. As a CAIR user, you must: Have the patient or parent/guardian complete a CAIR Decline or Start Sharing/Information Request Form. File this original form in the patient s medical record. Fax (see bottom of form for fax number), email or mail a copy of the signed CAIR Decline or Start Sharing/Information Request Form to CAIR Inland Empire Region. You may provide a copy of this form to the patient or parent/guardian. Other patient forms You can download these forms from the website: Decline or Start Sharing/Information Request Form A patient or parent/guardian retains the right to change their mind and opt to have their information stored in the Registry. Instruct the patient or parent/ guardian to complete a CAIR Decline or Start Sharing/Information Request Form. Patient request for information A patient or parent/guardian may request a list of the providers or agencies that have accessed their/their child s information in the Registry. Instruct the patient or parent/guardian to call the CAIR Help Desk to obtain a copy of the CAIR Decline or Start Sharing/Information Request Form. 2
Section 2 Welcome to the Registry Logging into CAIR 1 Double-click on the VAXTRACK shortcut from your desktop. Or point your browser to http://cair-ie.cairweb.org 2 Click the User Log In button to view the Log In screen. 3 Type in the following information: Provider (Group) ID = Your clinic s issued Provider Group ID User ID = Your first initial + first 3 letters of last name + Last 4 digits of SSN Password = Passwords are case-sensitive, must be 8 to 12 characters in length, and have both letters and numbers. No special characters are permitted (#,!, @, etc.). 4 Click Login to view the Session Default screen. 5 Select the following applicable information (you may not need to change any information): Working Provider ID If your clinic has multiple sites, select the location where you are working at that day. Operational Code If more than one of your clinic sites share the same inventory. Admin by Select the name of the person physically giving the shots. If you are a shot giver, your name should automatically appear. 6 Click Set Session Default to save. 3
Welcome to the Registry Section 2 A note to first time users Users are required to change their password and set their challenge phrase the first time they sign in to CAIR. If you are not automatically prompted to do so, then follow the steps listed below. Changing your user password 1 Click on the Change User Password link under the Local Administration section in the Main Menu (bottom right). 2 Type in your Old Password. 3 Type in your New Password. Passwords are case-sensitive, must be 8 to 12 characters in length, and have both letters and numbers. No special characters are permitted (#,!,@, etc.). 4 Retype your password in the Retype New Password field. 5 Click Set New Password to save. Entering a challenge phrase By entering an answer to a challenge question, you will be able call the Help Desk directly to reset your password should you ever forget it. If you do not set a challenge phrase, you must resubmit paperwork to get a new password. Click on the Change Challenge Phrase link under the Local Administration section of the Main Menu (bottom right). Select a challenge question from the Save Challenge Phrase drop-down list. Type in the answer to the question in the Enter the answer field. Click Save Challenge Phrase to save. 4
Section 3 Data entry functions Searching for a patient 1 At the top left of the Main Menu screen Click on Patient Search. 2 If you have a patient ID Number, type in the number and click on Find Patient NOTE: The easiest way to find a patient in the Registry is to enter a patient s CAIR ID Number. If you have this information: Type the patient s CAIR ID Number in the ID Number field. Click Find Patient at the bottom of the screen. 3 If you DO NOT have an ID Number you will need to type ONLY two fields: Be sure to use all CAPS. Type the Patient s Last Name and Patient s First Name. If you are uncertain about the spelling of a name, try using a wildcard search to better your chances of finding the record. Click Find Patient at the bottom of the screen. No match? Delete the first name field and search using the first three letters of the last name followed by the * key and the date of birth. 4 Click Find Patient at the bottom of the page. If a patient record is found, click on the ID link to the left of the patient s name to access the patient s record. This will bring you to the Patient Immunization History screen. TAKE SPECIAL NOTE Use a wildcard search for patients with names that are easily misspelled. You need at least the first three letters of the name and an asterisk (*) [Hold <Shift> while pressing <8>]. YOU VE BEEN WARNED! Enter all data in CAPITAL letters. Press your <CAPS LOCK> key once you have signed in. This will result in a search for all patients whose name starts with those letters. 5
Data entry functions Section 3 If no patient records are found If a No patient record is found to match your query requirement message appears on your screen after your first search, CAIR suggests that you search two more times before creating a new record. Common searches of patient information include: Patient s First Name and Patient Date of Birth Or Patient s Last Name and Patient Date of Birth Or Patient s First Name and Patient Date of Birth If you are unable to find any matches after searching three times, then you must add the patient to the Registry. Please refer to the Entering a new patient section on page 8. Selecting a patient record If one to ten records match your search crieteria, simply click on the ID link to the left of the patient s name to access their record. If your search produces more than 10 results, narrow your search by adding an additional field: 1 Type into one additional field on the Patient Search screen. (Use the gender field M/F) 2 Click Find Patient at the bottom of the screen. 3 Click on the ID link to the left of the patient s name to access their record. 6
Updating an existing record If you find the patient s record in CAIR, be sure to update the Address and Preferences screens at every visit before you do anything else within the record. Address screen 1 Update the fields listed below: Street address Zip Code Phone number 2 If your clinic received returned mail from this address, select Yes in the Returned Mail drop-down list. 3 Click Update Patient Info to save your changes. Preferences screen Update/verify the fields listed below: Primary Provider ID to your clinic if your patient will return to your facility for shots. Patient Status to give you an accurate account of your current patients, by noting if a patient is currently active, has moved, been lost to follow-up, etc. Updated status will help for clinic assessments done by your clinic, the health department, VFC, or health plans. Primary Language of patient if not previously selected. Click Update Patient Info to save your changes. Other Info 1 Update/verify the patient s race code in the Registry by selecting from the drop down. 2 Click Update Patient Info to save your changes. 7
Data entry functions Section 3 Entering a new patient 1 Type/Select the fields listed below: Patient s Last Name Type it in as it appears on the yellow card Patient s First Name Gender Male, Female, Other, or Unknown DOB Date slashes auto-fill; type in the date with the four digit year Mother s Last Name Type in if different from patient s last name Mother s First Name Type in UNKNOWN if this information is unavailable Has patient been disclosed? Select Yes from the drop-down list Disclosure Date today s date will auto-fill By Whom your clinic ID will auto-fill Has patient agreed to share? Select Yes or No (whichever applies), from the drop-down list VFC Eligibility 5-Not VFC-Eligible includes patients with Healthy Families, private insurance, are private pay, or are 19y and older Multiple Birth If patient is a twin, triplet, etc., select Yes from the drop-down list Street1 Enter the street address, including apartment number, on one line Zip Code-City and County will auto-fill Phone Dashes and parentheses are auto-filled 2 Click Create New Patient (bottom left). 3 Write the Patient ID number in/on your medical record for future reference. 4 Click Continue to go to the Patient Immunization History screen. 5 Click on Parent/Guardian and update information if available. 8
Entering additional information If the mother s name is not available If you were unable to input the mother s information on the Add New Patient screen, enter the father or guardian s information. To enter additional parent/guardian information: 1 Click on the Parent/Guardian link on the Patient Immunization History screen. 2 Type in the information in the appropriate fields. 3 Click Update Patient Info to save your changes. Preferences To enter the patient s language you would do the following: Click on the Preferences link on the Patient Immunization History screen. Enter/Select the Primary Language that applies by selecting from the drop down or typing the first letter of the language until you see the one that applies Verify that the Primary Provider ID and the Patient Status are correct. Click on Update Patient Info 9
Data entry functions Section 3 If you have a medical record number or other unique identifier If you would like to enter your clinic s medical record number in the patient s record in the Registry: Click on the Patient IDs link on the Patient Immunization History screen. Click All Identifiers to bring up the Patient ID list screen. Click Add Identifier to bring up the Patient Identifier screen. Type/Select in the information in the appropriate fields. Click Add Identifier to save your changes. Other Info To enter the patient s race code in the Registry: 1 Click on the Other Info link on the Patient Immunization History screen. 2 Select the Race Code from the drop down at the bottom of the screen. 3 Click on Update Patient Info 4 Click on the History link to begin entering immunization information 10
1 Entering historical shots If a patient has a previous shot record or yellow card, enter these historical shots on the Vaccination Quick Entry form: 1 Click the Quick button. 2 Click Show to display vaccine descriptions. 3 Type in the dates of previous vaccinations in the appropriate Vac Date fields. 4 Click Save Vaccination to save dates. Entry Tips Put in your combination (blue) vaccines first. DTaPHBIP TRADE NAME: Pediarix MAY APPEAR AS: PED, PDX, PRX, or P DTaPIPHi TRADE NAME: Pentacel DTaP-IPV TRADE NAME: KINRIX HIB-HBV TRADE NAME: Comvax MAY APPEAR AS: Com, CX, or C MMR-VZV TRADE NAME: ProQuad MAY APPEAR AS: MMRV Then enter the other commonly used (orange) vaccines. Avoid the following mistakes: Entering the wrong type of HIB HIB has two vaccines. Each vaccine has its own schedules. HIBPEDVX is often noted as PRP-OMP or PDVX on yellow cards. Confusing HBV with HPV HBV is for Hepatitis B while HPV (Gardasil ) prevents some strains of Human Papilloma Virus. Entering the wrong pneumococcal vaccine PNUCon(PCV) (Prevnar ) is used for children under the age of two. PNUps is reserved for persons two years and older at increased risk for the disease. 11
Data entry functions Section 3 8 Entering new shots 1 Note: Inventory MUST be entered prior to entering new shots. See Inventory Guide. 2 To enter new shots, click the New button. Or click on one of the vaccines under the Recommendations window (Preferred method). 3 Select the appropriate choice from each of the following fields: Vaccine Lot Number Body Site Code Admin By Verify the shot giver name 4 Click on either Save and Close or Save and Continue. 5 The updated shots should show in the Immunization History window of the Patient Immunization History screen. Optional features Click on the Why button to view an explanation of the shots listed in the Immunization History window. This feature is useful in diagnosing invalid shots (no number listed in the Seq column). Check the Accelerated Schedule box to view the "catch-up schedule" date (earliest allowable time to give the vaccine). Click on the Create New Siblings link to add additional family members. Many fields for the new sibling will be filled in on the Add New Patient screen. YOU VE BEEN WARNED! Errors in transcribed vaccine dates can be either updated or deleted by selecting the specific vaccine in the Immunization History window 12
Special functions 1 Waivers Waivers are used to record refusals and deferrals. Click on the Waivers link from the Immunization History window Select/type the vaccine type, waiver type, waiver effective dates, your first initial and last name as the waiver authorizer, and any pertinent details. 2 Notes DO NOT include any sensitive medical or private information, as other users will be able to view and edit this screen. Each entry should include: 1) date, 2) note, and 3) first initial and last name of the note writer. 3 Adverse reactions Click on the vaccine link from the Immunization History window. Click on the Adverse Reaction link on the Update Vaccination screen. Type in the reaction date and a note. If you report the reaction to VAERS (Vaccine Adverse Event Reporting System), input the date of report. 4 Risks Risks can be used to list pending risks for a specific vaccination. 5 Had chickenpox Click on the Had Chickenpox link and a window will open. VZV will be excluded from the Recommendations window once the disease is noted. 13
Data entry functions Section 3 Patient reports 1 After entering ALL shot information, click the Report link on the top right of the Patient Immunization History screen. 2 If there is an entry under Notes in the previous screen, be sure to check the Show Patient Notes box at the bottom of the screen. 3 Click the Run button next to the report you want to print. You will usually print the following three reports: Official Immunization Record (yellow card) Official Immunization Record (yellow card) - To be given to the patient and printed on yellow paper. 14
Detailed Immunization Report To be placed in the chart and printed on white paper. Do NOT print out the Immunization Report and History report as a substitute for this report. While it may look similar to the IMM- 542 form that you maintain in your medical records, this report is incomplete for documenting immunizations. Routing Slip A helpful tool that indicates what shots can/should be given to the patient. This is printed after transcribed information (i.e. Immunization History) is recorded in the Registry. 15
Data entry functions Section 3 Data Entry Guidelines for CAIR DO NOT USE Browser Back and Forward Buttons while in CAIR. Use ONLY the navigational features within the CAIR software itself. Mouse Clicks in CAIR are like web surfing. If you see a hyperlink or a button, click once to activate it. Be careful to always click once then wait. DO NOT double-click. ALL CAPS all the time for EVERYTHING. Weber should be WEBER. Names: Self-Report by patient/parent- Verify from patient/parent the spelling and if they have an apostrophe, hyphen, or space in their name. Dates: Type leading zeros (0) for 1-digit days and months. Type 4-digit years. For 1/1/02, type 01/01/2002 (slashes (/) are automatically filled in). Fields with asterisks (*) next to them are REQUIRED fields in CAIR and MUST be filled in. Additional fields NOT with asterisks (*) are REQUIRED such as Mother s Maiden Name (Parent Guardian Tab), Preferred Language (Preferences Tab), and Race Code (Other Info Tab). SSN-CAIR does NOT recommend entering social security numbers. In Riverside County, CAIR Inland Empire is made possible by grants from the California Department of Public Health, Immunization Branch, and First 5 Riverside the Riverside County Children and Families Commission. 16