Age: 49.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Extra dose administered, Feeling abnormal, Injection site erythema, Injection site warmth
Clinical narrative: Patient came in to office on 07/14/2021. Patient came up to vaccine table and presented her Covid vaccine card to care person. Patient?s vaccine card was given to care person. Once care person saw patient's Covid vaccine card we saw the card had the first and second dose of the Moderna covid vaccine was documented on the card from facility; the card was stamped twice from said facility. Patient was asked by care person if she had in fact received both covid vaccnine doses. Patient stated the vaccine stamps for both doses were done on the same day. Patent stated she had her first vaccine shot back in march and was not able to get second shot due to forgetting that the she had to go back. Pateint asked if she had to start all over with getting the vaccine administered. I and care person informed patient that if she had ?only one shot she did not have to start over, we can administer second shot today?. I asked patient ?if she was sure that she was administered only one shot from previous facility even though her card stated she was given both doses.? Patient stated she only received one shot, so  we  stated we could administered the second shot. After second shot was administered, patient?s original vaccine card was returned. We then also gave patient a new card showing that we administered her second  dose of the Covid Vaccine Moderna. Patient was then informed to wait the 15 minutes in room to be monitored.  After all shots were given for the clinic was completed.  I then started entering information into system. I looked up patient and saw that two doses of the covid vaccine was already inputted into system showing patient had received both covid vaccine shot previously before coming into clinic today.  I noticed system entry for both shots were from the same facility patient had on her original vaccine card. I told care person we discuss it and decided that our plan was to wait for coordinator to come back to office to discuss further action.   COVID coordinator  I called patient to confirm story, the patient expressed the same details as noted above. I requested for the patient to e-mail me a copy of her original card for documentation and the patient said she was on her way out she would stop by the office. When the patient got here, she showed me her card and all dates and lot numbers on card matched what was in system. I expressed to patient that if this were incorrect documentation by the facility, we would need to call them and have them fix it so that we may document her second vaccine. As I was giving the phone number to the patient, she begins to tell me that she does have a bad memory and she may have received the second dose already. I asked patient how she was feeling and requested to see the injection site. I did not see anything out of the ordinary, a little redness and warmth at the site. Patient stated that she was feeling bad on 07/15/2021 the day after vaccine administration, took some Tylenol and rested the rest of the day. Feels much better today. I expressed to patient that if ANYTHING changes, she needs to go straight to the ER and to call me after she was taken care of. Patient understood.