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Get Well Clinic: Health Summary

PatientIsabella 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_1 1.1.1.1.1.1.1.1.1
Document Created:August 6, 2012
Care provisionPnuemonia from August 6, 2012, 00:28 +0500 to August 6, 2012, 00:58 +0500
Performer (primary care provider)Dr. Henry Seven of Get Well Clinic
AuthorHenry 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, 00:28 +0500 to August 6, 2012, 00:58 +0500
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 6, 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 6, 2012
Contact info1002 Healthcare Drive
Portland, OR 97266, US
Tel: 555-555-1002
Document maintained byGet Well Clinic
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 Get Well Clinic 20120806

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
Admit Yourself to Community Health and Hospitals for Pnuemonia 20120806

REASON FOR REFERRAL

Recommend Admission to Community Health and Hospitals for Pnuemonia

PROBLEMS

  1. Pneumonia : Status - Active

PROCEDURES

Procedure Date
Chest X-Ray 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 Dates
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]