Age: 27.0
Sex: M
Vaccine: ANTH, FLUN4, TYP
Symptoms: No adverse event
Clinical narrative: Patient came in to pick up his medical records and mobilization packet mid October. On 21 Oct 2013 he went to get all of his requirements completed for his mobilization. On 31 Oct 13 he reported back with his records, however was missing medical notes regarding PHA and immunizations. This is not uncommon as most clinicians assume that everyone has medical access and can see/pull the information as needed, but we are not 100% online yet. Only 3 of 5 immunizations were documented in his medical record; however it was entered in database.  TIMELINE: 21 Oct 13 - Patient was given Typhoid, Anthrax, Flu and a PPD. Only the Flu was documented in his record from this date. They were also documented in database.  23 Oct 13 - Patient was inoculated with Smallpox in his RIGHT arm, which was also documented in his record.  31 Oct 13 - Patient reported with medical records to ensure all requirements were met prior to his ready to load date of Friday 1 Nov 13. I started going over the checklist and verifying everything was completed in the afternoon and when I got to the immunizations noticed that the Smallpox had been given, as was written, on 23 October 13. Two days after his other immunizations. I immediately tried contacting to verify if this was actually the date given or if it was a typo. I was looking specifically for the documentation of the vaccines given with dose, route, site, etc. that would normally be documented in the medical record, or if that wasn't available then a log book, or something showing who administered the vaccines. I was given the runaround by several different people in immunizations, medical records and on the main phone line. I asked to speak to the person in charge and was told he was on leave. When I asked to speak to the Chief, I was told he was also on leave. When I asked who was left in charge no one seemed to know who was running the show. Eventually I was given a name. I spoke to person and he told me that I would need to speak to the people in immunizations to find out the information I needed. Dead end once again. I put everything away for the evening and secured. 1 Nov 13 - Called and spoke to someone regarding the incident as she does handle all of our mobilizations. I was able to get person who was standing in charge at the time number, from her. When speaking to him he took the whole story, said that he really wasn't familiar with immunizations and their processes/procedures, but that he would turn it over to someone else, ASAP. Person called me not long after to ask for the story again, to hear it firsthand. I told him everything that had happened and he said that he was going to have a talk with the person and would take care of it.  On this date I was also advised to post an ICE comment card in regards to this situation, which I did. I received a phone call at 0815 Tuesday morning 11/5/13 giving me an update on patient and the immunization situation we had last week. Patient was seen Monday 11/4/13, and given a thorough exam, as well as counseling on what symptoms to look for should any arise. He was told to return to the clinic immediately if he had any problems at all. I have talked to patient on several occasions educating him on what to look for and what to do should he have any reactions since last Thursday when the issue was identified as well, and contacted him again Tuesday to reiterate the procedures for being seen.  He also acknowledged the ICE comment that I sent on Friday and said that there had been remedial training put in place for the person responsible for the mishap, as well as refresher training for the rest of the clinician's that are responsible for administering immunizations.  As of 11/8/13-Patient is doing well. Has no complaints and no symptoms. Will follow up with him again next week to ensure nothing has changed.