Patient | Myra Jones |
Date of birth | May 1, 1947 |
Sex | Female |
Race | White |
Ethnicity | Not Hispanic or Latino |
Contact info | Primary Home: 1357 Amber Drive Beaverton, OR 97006, US Tel: (816)276-6909 |
Patient IDs | 1 2.16.840.1.113883.4.6 123-10-5230 2.16.840.1.113883.4.1 |
Document Id | ToC_4 1.1.1.1.1.1.1.1.1 |
Document Created: | September 12, 2012, 00:00:00 -0000 |
Care provision | Pnuemonia 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 |
Author | Dr Henry Seven |
Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002 |
Encounter Id | 1 2.16.840.1.113883.4.6 |
Encounter Type | Pnuemonia |
Encounter Date | From August 6, 2012 to August 13, 2012 |
Encounter Location | id: 2.16.840.1.113883.4.6 |
Responsible party | Dr Henry Seven |
Personal relationship | Mr. Ralph Jones |
Contact info | Primary Home: 1357 Amber Drive Beaverton, OR 97006, US Tel: (555)555-2006 |
Personal relationship | Mr. Frank Jones |
Contact info | Primary Home: 1357 Amber Drive Beaverton, OR 97006, US Tel: (555)555-2006 |
Entered by | Mary McDonald |
Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002 |
Signed | Henry Seven at August 13, 2012 |
Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002 |
Informant | Henry Seven |
Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002 |
Informant | Frank 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 info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002 |
Document maintained by | Community Health and Hospitals |
Contact info | Work Place: 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002 |
Substance | Reaction | Severity | Status |
---|---|---|---|
Codeine | Shortness of Breath | Moderate | Active |
Encounter | Performer | Location | Date |
---|---|---|---|
Pnuemonia | Dr Henry Seven | Community Health and Hospitals | 20120806 |
Father (deceased)
Diagnosis | Age At Onset |
---|---|
Myocardial Infarction (cause of death) | 57 |
Diabetes | 40 |
Vaccine | Date | Status |
---|---|---|
Influenza virus vaccine | May 2012 | Completed |
Tetanus and diphtheria toxoids | April 2012 | Completed |
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 |
Planned Activity | Planned Date |
---|---|
Consultation with Dr George Potomac for Asthma | 20120820 |
Chest X-ray | 20120826 |
Sputum Culture | 20120820 |
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 |
Follow up with Dr George Potomac for Asthma
Procedure | Date |
---|---|
Chest X-Ray | 8/7/2012 |
Functional Condition | Effective Dates | Condition Status |
---|---|---|
Dependence on cane | November 1, 2008 | Active |
Memory impairment | November 1, 2008 | Active |
Result Type | Result Value |
---|---|
HGB | 10.2 g/dL |
WBC | 12.3 10*3/uL |
PLT | 123 10*3/uL |
Social History Element | Description | Effective Dates |
---|---|---|
smoking | Former Smoker (1 pack per day | 20050501 to 20110227 |
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] |