Adverse Event Report

Field Content
VAERS_ID 1066767
RECVDATE 2021-03-02
STATE NV
AGE_YRS 54
CAGE_YR 54
CAGE_MO
SEX M
RPT_DATE
SYMPTOM_TEXT Patient presented for 1st dose Moderna, when entering information into EMR an alert came up that the patient had a Pfizer COVID 19 vaccine on 12/15/2020 at another Medical Center. We share an EMR with them. Patient contacted on 3/2/2021. He stated he did not have a vaccine on 12/15/2020 and had never been to another hospital. He was advised to contact other hospitals HIM department. He will continue to receive his second dose at the due time.
DIED
DATEDIED
L_THREAT
ER_VISIT
HOSPITAL
HOSPDAYS
X_STAY
DISABLE
RECOVD
VAX_DATE 2021-02-23
ONSET_DATE 2021-02-23
NUMDAYS 0
LAB_DATA
V_ADMINBY OTH
V_FUNDBY
OTHER_MEDS
CUR_ILL
HISTORY
PRIOR_VAX
SPLTTYPE
FORM_VERS 2
TODAYS_DATE 2021-03-02
BIRTH_DEFECT
OFC_VISIT
ER_ED_VISIT
ALLERGIES
SYMPTOMS
  • No adverse event

Vaccines

COVID19 (COVID19 (MODERNA))
Field Content
VAERS_ID 1066767
VAX_TYPE COVID19
VAX_MANU MODERNA
VAX_LOT 001A21A
VAX_DOSE_SERIES 1
VAX_ROUTE IM
VAX_SITE RA
VAX_NAME COVID19 (COVID19 (MODERNA))
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