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Get Well Clinic: Health Summary

Patient	Isabella 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_1 1.1.1.1.1.1.1.1.1
Document Created:	August 6, 2012

Care provision	Pnuemonia 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

Author	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, 00:28 +0500 to August 6, 2012, 00:58 +0500
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 6, 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 6, 2012
Contact info	1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002

Document maintained by	Get Well Clinic
Contact info	Work Place: 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002

Table of Contents

ALLERGIES, ADVERSE REACTIONS, ALERTS
ENCOUNTERS
IMMUNIZATIONS
Medications
CARE PLAN
REASON FOR REFERRAL
PROBLEMS
PROCEDURES
FUNCTIONAL STATUS
RESULTS
SOCIAL HISTORY
VITAL SIGNS

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

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]