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170.315_b1_toc_amb_ccd_r21_sample1 test data

PatientAlice Newman
Date of birthMay 1, 1970
SexFemale
RaceWhite
EthnicityNot Hispanic or Latino
Contact info Primary Home:
1357 Amber Dr
Beaverton, OR 97006, US
Tel: +1(555)-777-1234
Patient IDs444222222 2.16.840.1.113883.4.1
Document Idds4p_2 2.16.840.1.113883.19.5.99999.1
Document Created:June 22, 2015
Care provisionFever from June 22, 2015, 10:00, EST to June 22, 2015, 10:30, EST
Performer (primary care physician)Dr Albert Davis of Neighborhood Physicians Practice
Performer Tracy Davis
AuthorDr. Davis Albert, Neighborhood Physicians Practice
Contact info2472 Rocky place
Beaverton, OR 97006, US
Tel: +1(555)-555-1002
Encounter Id9937012 2.16.840.1.113883.19
Encounter Date From June 22, 2015, 10:00, EST to June 22, 2015, 10:30, EST
Personal relationshipMr Rick Holler

Contact info Primary Home:
1357 Amber Dr
Beaverton, OR 97006, US
Tel: +1(555)-723-1544
Personal relationshipMr Matthew Newman
Contact info Primary Home:
1357 Amber Dr
Beaverton, OR 97006, US
Tel: +1(555)-723-1544
Entered byTracy Davis
Contact info2472 Rocky place
Beaverton, OR 97006, US
Tel: +1(555)-555-1002
Signed Dr Albert Davis at June 22, 2015
Contact info2472 Rocky place
Beaverton, OR 97006, US
Tel: +1(555)-555-1002
InformantAlbert Davis
Contact info2472 Rocky place
Beaverton, OR 97006, US
Tel: +1(555)-555-1002
InformantMatthew Newman
Information recipient:Dr Albert Davis
Legal authenticatorThis is not intended and not fully compliant with ONC Certification Dr Albert Davis signed at June 22, 2015
Contact info2472 Rocky place
Beaverton, OR 97006, US
Tel: +1(555)-555-1002
Document maintained byNeighborhood Physicians Practice
Contact info Work Place:
2472 Rocky place
Beaverton, OR 97006, US
Tel: +1(555)-555-1002

Table of Contents


Security and Privacy Prohibitions

Section Author: Dr. Davis Albert, Neighborhood Physicians Practice
Section Author: Dr. Davis Albert, Neighborhood Physicians Practice
PROHIBITION ON REDISCLOSURE OF CONFIDENTIAL INFORMATION:
This notice accompanies a disclosure of information concerning a client in alcohol/drug treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

ALLERGIES AND ADVERSE REACTIONS

Substance Reaction Severity Status
Penicillin G benzathine Hives Moderate Active
Ampicillin Sodium Hives Moderate Active

MEDICATIONS

Medication Directions Start Date
Ceftriaxone 100MG/ML BID June 22, 2015
Tylenol 500mg For 10 days As needed June 22, 2015
Darbepoetin Alfa 0.5 MG/ML Once a week June 22, 2015

PROBLEMS

Active Concerns

Resolved Concerns

ENCOUNTERS

Encounter Diagnosis Location Date
Fever Neighborhood Physicians Practice June 22, 2015 at 10am EST

IMMUNIZATIONS

Vaccine Date Status
Influenza Virus Vaccine May 10, 2014 Completed
Tetanus and diphtheria toxoids January 4, 2012 Completed
influenza, intradermal, quadrivalent, preservative free June 22, 2015 Refused by Patient

VITAL SIGNS

Date / Time: June 22, 2015
Height 177 cm
Weight 88 kg
Blood Pressure 145/88
Heart Rate 80 beats per minute
O2 Percentage BldC Oximetry 95 percent
Body Temperature 38 degree celsius
Respiratory Rate 18 breaths per minute

SOCIAL HISTORY

Social History Observation Description Dates Observed
Smoking Status Heavy tobacco smoker May 1, 2005 - February 27, 2011
Current Smoking Status Current every day June 22, 2015

PROCEDURES

Procedure Date
Nebulizer Therapy June 22, 2015
Introduction of cardiac pacemaker system via vein October 5, 2011

RESULTS

Result Type Result Value Relevant Reference Range Interpretation Date
Color of Urine YELLOW YELLOW Normal 06/22/2015
Appearance of Urine CLEAR CLEAR Normal 06/22/2015
Specific gravity of Urine by Test strip 1.015 1.005 - 1.030 Normal 06/22/2015
pH of Urine by Test strip 5.0 pH 5.0 - 8.0 Normal 06/22/2015
Glucose [Mass/volume] in urine by test strip 50mg/dl Neg 06/22/2015
Ketones [Mass/Volume] in urine by test strip Negative Negative 06/22/2015
Protein[Mass/Volume] in urine by test strip 100mg/dl negative 06/22/2015

FUNCTIONAL STATUS

Functional Category Effective Dates
Dependence on Cane May 01, 2005

ASSESSMENTS

The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day.

TREATMENT PLAN

Hand-off Communication:

Planned Care Start Date
Urinanalysis macro (dipstick) panel June 22, 2015
Get an EKG done on 6/23/2015. June 23, 2015
Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure. June 23, 2015
Take Clindamycin 300mg three times a day as needed if pain does not subside. June 23, 2015 three times a day as needed
Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015. July 7, 2015

Goals Section

Goal Value Date
Get rid of intermittent fever that is occurring every few weeks (Visual Inspection) N/A June 23, 2015
Need to gain more energy to do regular activities (Visual Inspection) N/A June 23, 2015

Health Concerns Section

Observation Status Date
Chronic Sickness exhibited by patient Active June 22, 2015

Concern Status Date
Documented HyperTension problem Active June 22, 2015
Documented HypoThyroidism problem Active June 22, 2015
Watch Weight of patient Active June 22, 2015

REASON FOR REFERRAL

Ms Alice Newman is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia.

MENTAL STATUS

Status Date
Amnesia May 05, 2005