170.315_b1_toc_inp_ccd_r21_sample2 test data (July 22, 2015, 6PM -0500)

Patient Legal: Jeremy V WONG jr Date of Birth: June 1, 1980 (35yr) Gender: Male Patient-ID:  116263337 (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

Substance Reaction Severity Status
Product containing benzodiazepine Allergic Headache Mild Active

MEDICATIONS

Medication Directions Start Date
Ceftriaxone 100MG/ML Two Times Daily June 22, 2015
Vantin Two Times Daily June 22, 2015
Tylenol 500mg As needed June 22, 2015
Clindamycin 300mg Three Times Daily June 23, 2015
Torsemide 20mg Daily June 23, 2015
Levothyroxine Sodium Daily June 23, 2015
Prednisolone 10mg Daily June 23, 2015
FenoFibric Acid 35mg At the hour o sleep June 24, 2015
Mycophenolic Acid 360mg Two Times Daily June 24, 2015
Everolimus 0.5mg Two Times Daily June 24, 2015
Ciprofloxacin 2mg/ml Three Times Daily June 25, 2015

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 mm[Hg]
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
Gender Identity Asked but Unknown Unknown
Sexual Orientation Unknown Unknown
Basic Occupation Odd Jobs Day Worker June 22, 2022
Tribal Affiliation Coquille Indian Tribe June 22, 2022
Pregnancy Status Not Pregnant June 22, 2022

RESULTS

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

ASSESSMENTS

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

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

Goal Value Date
Achieve Food Security with appropriate help N/A July 22, 2015

Health Concerns

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.

REASON FOR REFERRAL

Ms Rebecca Larson is being referred to a Specialist for a Kidney examination.

MENTAL STATUS

No Mental Status information

FUNCTIONAL STATUS

Functional Category Effective Dates
Dependence on Cane May 01, 2005
Do you have serious difficulty walking or climbing stairs - Yes June 22, 2022

Care Team section

Performer Name Performer Role
Dr Henry seven Physician

Notes section

Summary Written by: Date
Dr Henry Seven diagnosed Mr Jeremy Wong to be suffering from first degree burns, but provided the necessary care and discharged Mr Wong letting him know that it would heal in time and he can go home. Dr Henry Seven 07/22/2020

Insurance Providers

Health Insurance Information
Document
ID ToC_7 (2.16.840.1.113883.19.5.99999.1)
Version 1
Set‑ID sTT105 (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: Jeremy V WONG jr Contact Details Home Primary: 1005 Amber Dr
Beaverton, OR 97006
US
Tel Mobile: +1(555)-221-1234, Tel Home Primary: +1(555)-222-1544
Date of Birth June 1, 1980 (35yr) Gender Male
Race unknown Ethnicity unknown
Patient-IDs 116263337 (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
 
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. Jae WONG, grandparent Contact Details Home Primary: 1005 Amber Dr
Beaverton, OR 97006
US
Tel Home Primary: +1(555)-222-1544
Indirect target - personal relationship SPOUSE Ms Ira WONG, SPOUSE Contact Details Home Primary: 1005 Amber Dr
Beaverton, OR 97006
US
Tel Home Primary: +1(555)-222-1544
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 Ira WONG
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