Documenting Medical Exemptions
Documentation in the Patient’s Medical Record
When a medical exemption is provided, the patient’s medical record should clearly document findings, describe the reason for the medical exemption, specify the duration of the exemption, and demonstrate that it is consistent with standards of care for contraindications and precautions.10,11
Documentation for School Admission
In addition to documenting the exemption in the medical record, the physician should provide the parent/guardian with a written statement of the exemption for submission to school. Current law requires written documentation for medical exemptions to include: (1) a general statement that a physical or medical condition exists that medically exempts the patient from immunization(s), (2) the specific immunization(s) from which the patient is exempted, and (3) the expected duration of exemption.6
Starting on July 1, 2019, the written statement for temporary and permanent medical exemptions requires the following4:
- The specific nature of the physical or medical circumstance (not simply the presence of one) exempting the patient from the immunization(s)
- The expected duration of the specific physical or medical circumstance, specifying the probable timeframe for temporary exemptions or that the circumstance is permanent
- The specific required vaccine(s) from which the patient is exempt
- For temporary medical exemptions, the expiration date for each vaccine exemption, which now cannot exceed 12 months from the date that the exemption was signed.
In some instances, students with medical exemptions on file prior to July 1, 2019 will need to be reevaluated. For instance, if a temporary medical exemption has expired or if a prior exemption does not meet the new requirements when the child is admitted at a pre-kindergarten facility or TK/K-12 school, the child will need to be reassessed by a physician and if appropriate, issued a new medical exemption.7