Get Well Clinic: Health Summary (August 6, 2012)

Patient Legal: Isabella Isa 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: August 6, 2012 00:28AM +0500 - 00:58AM +0500
Documentation Of Care provision, Pnuemonia, Date/Time: August 6, 2012 00:28AM +0500 - 00:58AM +0500, Performer: Dr. Henry SEVEN
Author Henry SEVEN, Authored On: August 6, 2005
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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 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]
Document
ID ToC_1 (1.1.1.1.1.1.1.1.1)
Created On August 6, 2012
Custodian Get Well Clinic Contact Details Workplace: 1002 Healthcare Drive
Portland, OR 97266
US
Tel Workplace: 555-555-1002
 
Patient Legal: Isabella Isa 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
Get Well Clinic
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 PnuemoniaAugust 6, 2012 00:28AM +0500 - 00:58AM +0500
Performer - Primary Care Provider - Primary Care Provider Dr. Henry SEVEN of Get Well Clinic Contact Details 1002 Healthcare Dr
Portland, OR 97266
US
Tel Workplace: +1-555-555-5000
Encounter
ID 1 (NPI)
Type Pnuemonia
Encounter Date August 6, 2012 00:28AM +0500 - 00:58AM +0500
Encounter Location ID:2.16.840.1.113883.4.6
Responsible Party Dr Henry SEVEN
attender Dr Henry SEVEN
 
Author Henry SEVEN - Code: Allopathic & Osteopathic Physicians 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
Get Well Clinic
Contact Details (Organization)
Authenticator Henry SEVEN signed at August 6, 2012 Contact Details 1002 Healthcare Drive
Portland, OR 97266
US
Tel Workplace: 555-555-1002
Legal Authenticator Henry SEVEN signed at August 6, 2012 Contact Details 1002 Healthcare Drive
Portland, OR 97266
US
Tel Workplace: 555-555-1002