Age: 1.25
Sex: F
Vaccine: COVID19, FLU4
Symptoms: Extra dose administered
Clinical narrative: The client, was present in the clinic on 3/15/2024 accompanied by her father to receive her 2nd dose of the Moderna pediatric COVID vaccine. Per standard procedure, RN and RN provided the pre-vaccination education to the client?s father and a pre-vaccination screening was conducted, partly with information supplied by the client?s father (including a verbal accounting of her vaccination history). The client?s IIS and vaccination records were also reviewed.   RNs noted that the client records indicated that the client only received 1 flu vaccination previously, on 5/22/2023, which was confirmed by the client?s father. They educated the client?s father that Public Health- County Standing Orders state ?A second dose of influenza vaccine is recommended 4 weeks or more after the first dose for children age 6 months through 8 years if they have not or don?t know if they have received 2 doses in prior years (not necessarily in the same season.)?.   The father agreed to a flu vaccination at this appointment, along with the pediatric COVID vaccine she had originally been scheduled for. All information available to the vaccination team at the time was carefully reviewed and indicated that both vaccines were appropriate for this client. Per the vaccination team, the client received both vaccines (Moderna pediatric COVID vaccine, Lot# AU5554B to the LAT at 1458 and Fluzone Quadrivalent Lot# U8200AA to the RAT at 1459) and underwent the standard observation period without incident.   This writer had been absent from the clinic during this period, but the vaccination team asked him to call the client?s father when he returned, as the client's father had further questions about the second flu dose recommendation and they wished to ensure that his questions were answered.   When this writer called, the client?s mother, answered the phone. While this writer was in conversation with the client?s mother, she indicated that the client had actually received flu vaccines in June 2023 (to satisfy the 2-dose recommendation in conjunction with the 5/22/2023 vaccination) and in October 2023 (for the 2023-2024 seasonal vaccination). She reported that all vaccines were given at Clinic, but that the client?s father ?didn?t know about those vaccines, because he doesn?t usually bring her to medical appointments?. Neither the June 2023 nor the October 2023 vaccines are recorded in System or IIS, despite the 5/22/2023 vaccination being recorded in both. This writer recommended to the client?s mother that she contact Clinic regarding the lapse in documentation. She stated that she would.   This writer called provider Dr. to appraise her of the situation and seek her recommendation. She reported that this vaccination would only be a concern if the client has an allergic reaction to the vaccination. This writer informed the provider that the client showed no problems during observation and that her mother reported that she had been WNL in the period post-vaccination. Dr. then directed this writer to instruct the client?s parents that the vaccination would dissipate quickly, to watch for any signs or symptoms of an allergic reaction, and to reiterate the education regarding expected side effects and how to manage them. This writer called the client?s parents back to relay the provider?s recommendations and to outline the reporting process. The client?s mother verbalized understanding and repeated that the client was ?doing fine.?