Guide to Clinical Documentation 3rd Edition by Debra Sullivan

Exercise 7

You are performing a sports preparticipation physical on a 15-year-old boy. You review his immunization record and notice that he is due to receive a tetanus and diphtheria booster; however, his father refuses to consent for the vaccine. Access the Vaccine Information Sheet for tetanus and diphtheria at www.cdc.gov/vaccines/hcp/vis/ index.html and, using Example 5.1 as a guide, document the refusal.