170.315_b1_toc_amb_ccd_r21_sample1 test data (June 22, 2015)

Patient Legal: Myra Jones BANKS Date of Birth: June 1, 1970 (45yr) Gender: Female Patient-ID:  113243335 (SSN)
Encounter ID: 9937012 (Examples) , Date/Time: June 22, 2015 10:00AM -0500 - 10:30AM -0500
Documentation Of Care provision, Fever, Date/Time: June 22, 2015 10:00AM -0500 - 10:30AM -0500, Performer: Dr Albert DAVIS, Performer: Tracy DAVIS
Author Amb EMR v1.0, Organization: Neighborhood Physicians Practice, Authored On: June 22, 2015
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ALLERGIES AND ADVERSE REACTIONS

Substance Reaction Severity Status
Penicillin G Hives Moderate Active
Ampicillin Hives Moderate Active

MEDICATIONS

Medication Directions Start Date
Ceftriaxone 100 MG/ML Two Times Daily June 22, 2015
Tylenol 500mg As needed for 10 days June 22, 2015
Darbepoetin 0.5 MG/ML Once a week June 22, 2015

PROBLEMS

Active Concerns

  • Problem #1
    • Essential hypertension (Disorder)
  • Problem #2
    • Severe Hypothyroidism (Disorder)
  • Problem #3
    • Chronic rejection of renal transplant (disorder)
  • Problem #4
    • Fever (finding)

Resolved Concerns

  • Problem #5
    • Overweight (finding)

ENCOUNTERS

Encounter Diagnosis Location Date
Fever Neighborhood Physicians Practice June 22, 2015 at 10am EST

IMMUNIZATIONS

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

VITAL SIGNS

Date / Time: June 22, 2015
Height 177 cm
Weight 88 kg
Blood Pressure 145/88 mm[Hg]
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

Social History Observation Description Dates Observed
Smoking Status Heavy tobacco smoker May 1, 2005 - February 27, 2011
Current Smoking Status Current every day smoker June 22, 2015
Birth Sex Female June 22, 2015

PROCEDURES

Procedure Date
Nebulizer Therapy June 22, 2015
Introduction of cardiac pacemaker system via vein October 5, 2011

Implants

Implanted Area UDI
Cardiac Pacemaker Subclavian Vein (01)00643169007222(17)160128(21)BLC200461H

RESULTS

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 50 mg/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 100 mg/dL negative 06/22/2015

FUNCTIONAL STATUS

Functional Category Effective Dates
Dependence on Cane May 01, 2005

ASSESSMENTS

The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day.

TREATMENT PLAN

Hand-off Communication:

Planned Care Start Date
Urinanalysis macro (dipstick) panel June 29, 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

Goals Section

Goal Value Date
Get rid of intermittent fever that is occurring every few weeks (Visual Inspection) N/A June 22, 2015
Need to gain more energy to do regular activities (Visual Inspection) N/A June 22, 2015

Health Concerns Section

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

REASON FOR REFERRAL

Ms Myra Banks is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia.

MENTAL STATUS

Status Date
Amnesia May 05, 2005
Document
ID ToC_13 (2.16.840.1.113883.19.5.99999.1)
Version 1
Set‑ID sTT103 (2.16.840.1.113883.19.5.99999.19)
Created On June 22, 2015
Custodian Neighborhood Physicians Practice Contact Details Workplace: 2472 Rocky place
Beaverton, OR 97006
US
Tel Workplace: +1(555)-555-1002
 
Patient Legal: Myra Jones BANKS, Monet Jones BANKS Contact Details Home Primary: 1003 Amber Dr
Beaverton, OR 97006
US
Tel Mobile: +1(555)-115-1234, Tel Home Primary: +1(555)-116-1544
Date of Birth June 1, 1970 (45yr) Gender Female
Race White Ethnicity Not Hispanic or Latino
Patient-IDs 113243335 (SSN) Language Communication
en-US, Expressed spoken, preferred: yes
Provider Organization
Neighborhood Physicians Practice
ID 99999999 (NPI)
Contact Details (Organization) 2472 Rocky place
Beaverton, OR 97006
US
Tel Workplace: +1(555)-555-5000
 
Documentation Of - care provision FeverJune 22, 2015 10:00AM -0500 - 10:30AM -0500
Performer - Primary Care Provider - Primary Care Provider Dr Albert DAVIS of Neighborhood Physicians Practice Contact Details 2472 Rocky place
Beaverton, OR 97006
US
Tel Workplace: +1(555)-555-1002
Performer - Tracy DAVIS Contact Details 2472 Rocky place
Beaverton, OR 97006
US
Tel Workplace: +1(555)-555-1002
Encounter
ID 9937012 (Examples)
Encounter Date June 22, 2015 10:00AM -0500 - 10:30AM -0500
 
Author Amb EMR v1.0 - Code: Allopathic & Osteopathic Physicians, Organization: Neighborhood Physicians Practice Contact Details 2472 Rocky place
Beaverton, OR 97006
US
Tel Workplace: +1(555)-555-1002
Indirect target - personal relationship grandparent Mr Christopher JONES, grandparent Contact Details Home Primary: 1003 Amber Dr
Beaverton, OR 97006
US
Tel Home Primary: +1(555)-116-1544
Indirect target - personal relationship SPOUSE Mr Glazer BANKS, SPOUSE Contact Details Home Primary: 1003 Amber Dr
Beaverton, OR 97006
US
Tel Home Primary: +1(555)-116-1544
Data Enterer Tracy DAVIS Contact Details 2472 Rocky place
Beaverton, OR 97006
US
Tel Workplace: +1(555)-555-1002
Informant Albert DAVIS Contact Details 2472 Rocky place
Beaverton, OR 97006
US
Tel Workplace: +1(555)-555-1002
Informant Glazer BANKS
Information Recipient Dr Albert DAVIS
Organization
Neighborhood Physicians Practice
Contact Details (Organization)
Authenticator Dr Albert DAVIS signed at June 22, 2015 Contact Details 2472 Rocky place
Beaverton, OR 97006
US
Tel Workplace: +1(555)-555-1002
Legal Authenticator Dr Albert DAVIS signed at June 22, 2015 Contact Details 2472 Rocky place
Beaverton, OR 97006
US
Tel Workplace: +1(555)-555-1002