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Community Health and Hospitals: Health Summary

PatientMyra Jones
Date of birthMay 1, 1947
SexFemale
RaceWhite
EthnicityNot Hispanic or Latino
Contact info Primary Home:
1357 Amber Drive
Beaverton, OR 97006, US
Tel: (816)276-6909
Patient IDs1 2.16.840.1.113883.4.6
123-10-5230 2.16.840.1.113883.4.1
Document IdToC_11 1.1.1.1.1.1.1.1.1
Document Created:September 12, 2012, 00:00:00 -0000
Care provisionPnuemonia from August 6, 2012 to August 13, 2012
Performer (primary care provider)Dr. Henry Seven of Community Health and Hospitals
Performer (primary care provider)Dr. Henry Seven of Community Health and Hospitals
AuthorDr Henry Seven
Contact info1002 Healthcare Drive
Portland, OR 97266, US
Tel: 555-555-1002
Encounter Id1 2.16.840.1.113883.4.6
Encounter TypePnuemonia
Encounter Date From August 6, 2012 to August 13, 2012
Encounter Locationid: 2.16.840.1.113883.4.6
Responsible partyDr Henry Seven
Personal relationshipMr. Ralph Jones

Contact info Primary Home:
1357 Amber Drive
Beaverton, OR 97006, US
Tel: (555)555-2006
Personal relationshipMr. Frank Jones
Contact info Primary Home:
1357 Amber Drive
Beaverton, OR 97006, US
Tel: (555)555-2006
Entered byMary McDonald
Contact info1002 Healthcare Drive
Portland, OR 97266, US
Tel: 555-555-1002
Signed Henry Seven at August 13, 2012
Contact info1002 Healthcare Drive
Portland, OR 97266, US
Tel: 555-555-1002
InformantHenry Seven
Contact info1002 Healthcare Drive
Portland, OR 97266, US
Tel: 555-555-1002
InformantFrank Jones
Information recipient:Henry Seven
Legal authenticatorThis is not intended and not fully compliant with ONC Certification Henry Seven signed at August 13, 2012
Contact info1002 Healthcare Drive
Portland, OR 97266, US
Tel: 555-555-1002
Document maintained byCommunity Health and Hospitals
Contact info Work Place:
1002 Healthcare Drive
Portland, OR 97266, US
Tel: 555-555-1002

Table of Contents


ALLERGIES, ADVERSE REACTIONS, ALERTS

Substance Reaction Severity Status
Codeine Shortness of Breath Moderate Active

ENCOUNTERS

Encounter Performer Location Date
Pnuemonia Dr Henry Seven Community Health and Hospitals 20120806

FAMILY HISTORY

Father (deceased)

Diagnosis Age At Onset
Myocardial Infarction (cause of death) 57
Diabetes 40

IMMUNIZATIONS

Vaccine Date Status
Influenza virus vaccine May 2012 Completed
Tetanus and diphtheria toxoids April 2012 Completed

Medications

Medication Directions Start Date Status Indications Fill Instructions
Albuterol 0.09 MG/ACTUAT inhalant powder Albuterol 0.09 MG/ACTUAT inhalant powder, 2 puffs 20120806 Active Pneumonia (233604007 SNOMED CT) Generic Substitition Allowed

CARE PLAN

Planned Activity Planned Date
Consultation with Dr George Potomac for Asthma 20120820
Chest X-ray 20120826
Sputum Culture 20120820

HOSPITAL DISCHARGE MEDICATIONS

Medication Directions Start Date Status Indications Fill Instructions
120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler 0.11 MG/ACTUAT Metered Dose Once Daily 20120813 Active Bronchitis (32398004 SNOMED CT) Generic Substitition Allowed

REASON FOR REFERRAL

Follow up with Dr George Potomac for Asthma

PROBLEMS

  1. Pneumonia : Status - Resolved

PROCEDURES

Procedure Date
Chest X-Ray 8/7/2012

FUNCTIONAL STATUS

Functional Condition Effective Dates Condition Status
Dependence on cane November 1, 2008 Active
Memory impairment November 1, 2008 Active

RESULTS

Result Type Result Value
HGB 10.2 g/dL
WBC 12.3 10*3/uL
PLT 123 10*3/uL

SOCIAL HISTORY

Social History Element Description Effective Date
smoking Former Smoker (1 pack per day) 20050501 to 20110227

VITAL SIGNS

Date / Time: Nov 1, 2011 August 6, 2012
Height 175 cm 175 cm
Weight 88 kg 90 kg
Blood Pressure 132/86 mm[Hg] 145/88 mm[Hg]

HOSPITAL DISCHARGE INSTRUCTIONS

Ms. Jones, you have been seen by Dr. Henry Seven at Local Community Hospital from August 8th until August 13th 2012. You are currently being discharged from Local Community Hospital. Dr. Seven has provided the following instructions to you at this time; should you have any questions please contact a member of your healthcare team prior to discharge. If you have left the hospital and have questions, please contact Dr. Seven at 555-555-1002. Instructions:
  1. Take all medications as prescribed.
  2. Please monitor your peak flows. If your peak flows drop to 50% of normal, call my office immediately or return to the Emergency Room.
  3. If you experience any of the following symptoms, call my office immediately or return to the Emergency Room:
    1. Shortness of Breath
    2. Dizziness or Light-headedness
    3. Fever, chills, or diffuse body aches
    4. Pain or redness at the site of any previous intravenous catheter
    5. Any other unusual problem