Patient | Alice Newman |
Date of birth | May 1, 1970 |
Sex | Female |
Race | White |
Ethnicity | Not Hispanic or Latino |
Contact info | Primary Home: 1357 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-777-1234 |
Patient IDs | 444222222 2.16.840.1.113883.4.1 |
Document Id | ds4p_1 2.16.840.1.113883.19.5.99999.1 |
Document Created: | June 22, 2015 |
Care provision | Fever 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 |
Author | Dr. Davis Albert, Neighborhood Physicians Practice |
Contact info | 2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002 |
Encounter Id | 9937012 2.16.840.1.113883.19 |
Encounter Date | From June 22, 2015, 10:00, EST to June 22, 2015, 10:30, EST |
Personal relationship | Mr Rick Holler |
Contact info | Primary Home: 1357 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-723-1544 |
Personal relationship | Mr Matthew Newman |
Contact info | Primary Home: 1357 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-723-1544 |
Entered by | Tracy Davis |
Contact info | 2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002 |
Signed | Dr Albert Davis at June 22, 2015 |
Contact info | 2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002 |
Informant | Albert Davis |
Contact info | 2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002 |
Informant | Matthew 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 info | 2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002 |
Document maintained by | Neighborhood Physicians Practice |
Contact info | Work Place: 2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002 |
Substance | Reaction | Severity | Status |
---|---|---|---|
Penicillin G benzathine | Hives | Moderate | Active |
Medication | Directions | Start Date |
---|---|---|
Ceftriaxone 100MG/ML | Two Times daily | June 22, 2015 |
Tylenol 500mg | For 10 days As needed | June 22, 2015 |
Active Concerns
Resolved Concerns
Encounter Diagnosis | Location | Date |
---|---|---|
Fever | Neighborhood Physicians Practice | June 22, 2015 at 10am EST |
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 |
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 Observation | Description | Dates Observed |
---|---|---|
Smoking Status | Heavy tobacco smoker | May 1, 2005 - February 27, 2011 |
Current Smoking Status | Current every day | June 22, 2015 |
Procedure | Date |
---|---|
Nebulizer Therapy | June 22, 2015 |
Introduction of cardiac pacemaker system via vein | October 5, 2011 |
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 Category | Effective Dates |
---|---|
Dependence on Cane | May 01, 2005 |
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 |
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 |
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 |
Status | Date |
---|---|
Amnesia | May 05, 2005 |