What is the recommended SOAP (Subjective, Objective, Assessment, Plan) note for a flu vaccine, including ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes?

SOAP Note for Influenza Vaccine Administration

Subjective

• Chief Complaint: Patient presents for seasonal influenza vaccination
• History of Present Illness: Patient requesting/scheduled for annual influenza immunization for the 2024-25 season 1
• Review of Systems:
  • Assess for current moderate-to-severe acute illness with or without fever (precaution to vaccination) 1
  • Screen for history of severe allergic reaction to previous influenza vaccine or vaccine components 1
  • Screen for history of Guillain-Barré syndrome within 6 weeks of prior influenza vaccination 1
  • For LAIV candidates: assess for contraindications including pregnancy, immunocompromising conditions, aspirin therapy in children/adolescents, asthma in children 2-4 years 1

Objective

• Vital Signs: Temperature, blood pressure, pulse, respiratory rate documented
• Physical Examination: Patient appears well, no signs of acute illness
• Vaccine Selection (based on age and health status):
  • Ages ≥6 months: Quadrivalent inactivated influenza vaccine (IIV4) - Fluarix, FluLaval, Fluzone, or Afluria 1
  • Ages ≥6 months: Cell culture-based IIV4 (Flucelvax) 1
  • Ages 2-49 years (healthy, non-pregnant): Live attenuated influenza vaccine (LAIV4/FluMist) 1
  • Ages ≥65 years: High-dose IIV3 (Fluzone High-Dose) or adjuvanted IIV3 (Fluad) preferred 1, 2
  • Ages ≥18 years: Recombinant influenza vaccine (RIV4/Flublok) 1

Assessment

• Z23: Encounter for immunization 1
• Patient is appropriate candidate for influenza vaccination with no contraindications identified

Plan

Vaccine Administration:

• Route: Intramuscular injection 1, 3
• Site:
  • Adults and older children: deltoid muscle 1, 3
  • Infants and young children: anterolateral aspect of thigh 1, 3
  • Never use buttocks (risk of sciatic nerve injury and reduced immunogenicity) 3
• Needle angle: 90 degrees 3
• Needle length: >1 inch for adults/older children in deltoid; 7/8-1 inch for infants in thigh 3

Dosing:

• Children 6-35 months: 0.25 mL or 0.5 mL depending on product 1
• Children ≥36 months and adults: 0.5 mL 1
• Two-dose series required for children 6 months-8 years receiving influenza vaccine for first time (minimum 4 weeks apart) 1, 4

Post-Vaccination:

• Observe patient for 15 minutes for immediate adverse reactions 1
• Counsel on expected local reactions (soreness, redness at injection site in 10-64% of patients) 3
• Advise to return for second dose in 4 weeks if applicable 1
• Document vaccination in electronic health record and immunization registry 5

Follow-up:

• Return for annual influenza vaccination next season 1, 2
• Contact clinic if severe allergic reaction or concerning symptoms develop 1

Billing Codes

CPT Codes (select appropriate code based on vaccine administered):

• 90685: Influenza virus vaccine, quadrivalent, split virus, preservative free, 0.25 mL dosage, for intramuscular use (ages 6-35 months) 1
• 90686: Influenza virus vaccine, quadrivalent, split virus, preservative free, 0.5 mL dosage, for intramuscular use (ages ≥6 months) 1
• 90687: Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for intramuscular use 1
• 90674: Influenza virus vaccine, quadrivalent, cell culture-based, for intramuscular use 1
• 90682: Influenza virus vaccine, quadrivalent, recombinant, for intramuscular use (ages ≥18 years) 1
• 90662: Influenza virus vaccine, trivalent, high-dose, for intramuscular use (ages ≥65 years) 1
• 90653: Influenza virus vaccine, trivalent, adjuvanted, for intramuscular use (ages ≥65 years) 1
• 90672: Influenza virus vaccine, quadrivalent, live, for intranasal use (ages 2-49 years) 1

ICD-10 Code:

• Z23: Encounter for immunization 1