Medical Directive Support

Pharmacist-Initiated Immunization

Assess and prescribe adult vaccines under medical directive for uninsured, unattached, and at-risk populations. Generates a clinical PMS note, physician notification PDF, and pharmacy prescription. Supports multiple vaccines per encounter.

Directive & Service Details

Practice Site

Implementing Pharmacist

Authorizing Physician

Date of Service

Data

Patient Information

Patient Name

Date of Birth

General Exclusion Criteria Screen (applies to entire encounter)

Patient does NOT meet any of the following. Check all that apply — if any are present, decline the service and refer to the patient's primary care provider or public health immunization clinic.

Patient meets one or more exclusion criteria — decline the service and refer to primary care provider or public health. Do not proceed with prescribing under this directive.

Vaccine Encounter

Vaccine(s) Assessed & Prescribed — add one or more vaccines for this encounter

Assessment

Contraindication Assessment

No contraindications identified for any vaccine above; patient eligible for vaccination (PASS)

Clinical Notes / Rationale

Optional — document any shared decision-making, risk/benefit discussion (e.g., inactivated vaccine in pregnancy), or other clinical context relevant to this encounter.

Plan

Post-Vaccination Monitoring

Observation Period

Primary Care Provider (if different from Authorizer)

Patient Consent & Education

Informed consent obtained; patient advised service is provided under medical directive authorized by the Authorizing Physician Patient informed of cost (uninsured/private-pay service) versus option to wait for public funding, if applicable Patient education provided (expected reactions, comfort measures, warning signs requiring urgent care)

Pharmacist-Initiated Immunization

PMS Note Preview