Community Health and Hospitals: Health Summary (September 12, 2012, 00AM -0000)

Patient Legal: Myra JONES Date of Birth: May 1, 1947 (65yr) Gender: Female Patient-ID:  1 (NPI), 123-10-5230 (SSN)
Guardian Ralph JONES - Grandfather
Encounter ID: 1 (NPI) , Type: Pnuemonia, Date/Time: from August 6, 2012 to August 13, 2012
Documentation Of Care provision, Pnuemonia, Date/Time: from August 6, 2012 to August 13, 2012, Performer: Dr. Henry SEVEN, Performer: Dr. Henry SEVEN
Author Dr Henry SEVEN, Authored On: August 13, 2005, 00AM +0500
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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
Document
ID ToC_11 (1.1.1.1.1.1.1.1.1)
Created On September 12, 2012, 00AM -0000
Custodian Community Health and Hospitals Contact Details Workplace: 1002 Healthcare Drive
Portland, OR 97266
US
Tel Workplace: 555-555-1002
 
Patient Legal: Myra JONES Contact Details Home Primary: 1357 Amber Drive
Beaverton, OR 97006
US
Tel Home Primary: (816)276-6909
Date of Birth May 1, 1947 (65yr) Gender Female
Race White Ethnicity Not Hispanic or Latino
Patient-IDs 1 (NPI)
123-10-5230 (SSN)
Language Communication
eng, Expressed spoken, preferred: yes
Guardian Ralph JONES - Grandfather Contact Details Home Primary: 1357 Amber Drive
Beaverton, OR 97006
US
Tel Home Primary: (816)276-6909
Provider Organization
Community Health and Hospitals
ID 1.1.1.1.1.1.1.1.4
Contact Details (Organization) 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: 555-555-5000
 
Documentation Of - care provision Pnuemoniafrom August 6, 2012 to August 13, 2012
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: +1-555-555-5000
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 Home Primary: +1-555-555-5000
Encounter
ID 1 (NPI)
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
attender Dr Henry SEVEN
 
Author Dr Henry SEVEN Contact Details 1002 Healthcare Drive
Portland, OR 97266
US
Tel Workplace: 555-555-1002
Indirect target - personal relationship Grand Parent Mr. Ralph JONES, Grand Parent Contact Details Home Primary: 1357 Amber Drive
Beaverton, OR 97006
US
Tel Workplace: (555)555-2006
Indirect target - personal relationship SPOUSE Mr. Frank JONES, SPOUSE Contact Details Home Primary: 1357 Amber Drive
Beaverton, OR 97006
US
Tel Workplace: (555)555-2006
Data Enterer Mary MCDONALD Contact Details 1002 Healthcare Drive
Portland, OR 97266
US
Tel Workplace: 555-555-1002
Informant Henry SEVEN Contact Details 1002 Healthcare Drive
Portland, OR 97266
US
Tel Workplace: 555-555-1002
Informant Frank JONES
Information Recipient Henry SEVEN
Organization
Community Health and Hospitals
Contact Details (Organization)
Authenticator Henry SEVEN signed at August 13, 2012 Contact Details 1002 Healthcare Drive
Portland, OR 97266
US
Tel Workplace: 555-555-1002
Legal Authenticator Henry SEVEN signed at August 13, 2012 Contact Details 1002 Healthcare Drive
Portland, OR 97266
US
Tel Workplace: 555-555-1002