170.315_b1_toc_inp_ds_r21_sample2 test data (July 22, 2015, 6PM -0500)

Patient Legal: William DOSSIER jr Date of Birth: May 1, 1980 (35yr) Gender: Male Patient-ID:  119293340 (SSN)
Encounter ID: 9937012 (Examples) , Date/Time: July 22, 2015 6PM -0500 - 11PM -5000
Documentation Of Care provision, Burn by Fire, Date/Time: July 22, 2015 6PM -0500 - 11PM -5000, Performer: Dr Henry SEVEN, Performer: Mary MCDONALD
Author Dr Henry SEVEN, Authored On: July 22, 2015
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ALLERGIES AND ADVERSE REACTIONS

No Known Allergies

MEDICATIONS

No known Medications

Admission Medications

No Medications Administered

Discharge Medications

No Information

PROBLEMS

No known health problems

ENCOUNTERS

No Encounters

ADMISSION DIAGNOSIS

Skin burn

PROCEDURES

Procedure Date
Application of Dressing for burn July 22, 2015

MEDICAL EQUIPMENT

Patient has no history of implantable devices

IMMUNIZATIONS

No immunization history

VITAL SIGNS

Date / Time: June 22, 2015
Height 177 cm
Weight 88 kg
Blood Pressure 145/88
Date / Time: July 22, 2015
Body Temperature 99 degrees Fahrenheit

SOCIAL HISTORY

Social History Observation Description Dates Observed
Current Smoking Status Current every day July 22, 2015
Birth Sex Male July 22, 2015

RESULTS

Laboratory Test: None needed. Laboratory Values/Results: No Lab Result data

ASSESSMENTS

The patient Mr William Dossier was found to have first degree burns and Dr Seven and his staff Mr Dossier by cleaning the burn and dressing the burn and observed for couple of hours before discharging Mr Dossier.

TREATMENT PLAN

Hand-off Communication:

Planned Care Start Date
Schedule an appointment with Dr Seven after 1 week for Follow up with Outpatient facility. July 29, 2015
Medication: Tylenol 500mg As needed

Goals Section

No goal information

Health Concerns

No Known Health Concerns on 07/22/2015

HOSPITAL DISCHARGE INSTRUCTIONS

  1. Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility.
  2. In case of fever, take Tylenol as advised in plan of treatment.

MENTAL STATUS

No Mental Status information

FUNCTIONAL STATUS

No Functional Status information

HOSPITAL COURSE

Mr. William Dossier is a 35 year old male who is healthy and visits Community Health Hospitals on 7/22/2015 6pm EST due to a skin burn. The doctor examines the burn, applies the needed dressing and discharges the person after a few hours.

Discharge Diagnosis

The doctor examines the burn, applies the needed dressing and discharges the person after a few hours.
Document
ID ToC_5 (2.16.840.1.113883.19.5.99999.1)
Version 1
Set‑ID sTT108 (2.16.840.1.113883.19.5.99999.19)
Created On July 22, 2015, 6PM -0500
Custodian Community Health and Hospitals Contact Details 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: +1(555)-555-5000
 
Patient Legal: William DOSSIER jr Contact Details Home Primary: 1008 Amber Dr
Beaverton, OR 97006
US
Tel Mobile: +1(555)-227-1234, Tel Home Primary: +1(555)-228-1544
Date of Birth May 1, 1980 (35yr) Gender Male
Race unknown Ethnicity unknown
Patient-IDs 119293340 (SSN) Language Communication
en-US, Expressed spoken, preferred: yes
Provider Organization
Community Health and Hospitals
ID 99999999 (NPI)
Contact Details (Organization) 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: +1(555)-555-5000
 
Documentation Of - care provision Burn by FireJuly 22, 2015 6PM -0500 - 11PM -5000
Performer - Primary Care Provider - Primary Care Provider Dr Henry SEVEN of Community Health and Hospitals Contact Details 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: +1(555)-555-1002
Performer - Mary MCDONALD Contact Details 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: +1(555)-555-1002
Encounter
ID 9937012 (Examples)
Encounter Date July 22, 2015 6PM -0500 - 11PM -5000
Discharge Disposition Routine Discharge
 
Author Dr Henry SEVEN - Code: Chronic Disease Hospital Contact Details 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: +1(555)-555-1002
Indirect target - personal relationship grandparent Mr. Graham DOSSIER, grandparent Contact Details Home Primary: 1008 Amber Dr
Beaverton, OR 97006
US
Tel Home Primary: +1(555)-228-1544
Indirect target - personal relationship SPOUSE Ms Racheal DOSSIER, SPOUSE Contact Details Home Primary: 1008 Amber Dr
Beaverton, OR 97006
US
Tel Home Primary: +1(555)-228-1544
Data Enterer Mary MCDONALD Contact Details 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: +1(555)-555-1002
Informant Henry SEVEN Contact Details 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: +1(555)-555-1002
Informant Racheal DOSSIER
Information Recipient Dr Henry SEVEN
Organization
Community Health and Hospitals
Contact Details (Organization)
Authenticator Dr Henry SEVEN signed at July 22, 2015 Contact Details 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: +1(555)-555-1002
Legal Authenticator Dr Henry SEVEN signed at July 22, 2015 Contact Details 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: +1(555)-555-1002