There is a PPT slide in a meeting room showing how to write the medical record for the vaccine side effects.
Here it is:
Slide title: Medical record writing on the abnormal vaccine reactions
Subtitle: Precautions on the writing of abnormal reaction in medical record:
- Chief Complain: Not write the symptoms … after vaccination, Just write the symptoms…
- Current patient history: Not write the history of vaccination before the symptoms occurred. Only write the date of symptoms occurred such as year 2021 month xxx day xxx hour xxx second xxx what symptoms appeared etc.
- Past history: Write the date of Covid pneumonia vaccine on the year 2021 month xxx day xxx hour xxx second xxx in xxx vaccination site for a dose.
- Diagnosis: Not write the side effect of Covid vaccine. Allergic reaction is allowed to write if there is an allergic reaction. Other symptoms can be written as unknown headache, unknown seizure…. It is not allowed to put the vaccination as the cause in the diagnosis.