| Patient | Myra 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 2.16.840.1.113883.4.6 123-101-5230 2.16.840.1.113883.4.1 |
| Document Id | Test CCDA 1.1.1.1.1.1.1.1.1 |
| Document Created: | September 12, 2012, 00:00:00 -0000 |
| Care provision | Pnuemonia from August 6, 2012 to August 13, 2012 |
| Performer (primary care provider) | Dr. Henry Seven of Community Health and Hospitals |
| Performer (primary care provider) | Dr. Henry Seven of Community Health and Hospitals |
| Author | Dr 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 to August 13, 2012 |
| 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 13, 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 authenticator | Henry Seven signed at August 13, 2012 |
| Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002 |
| Document maintained by | Community Health and Hospitals |
| Contact info | Work Place: 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002 |
| Substance | Reaction | Severity | Status |
|---|---|---|---|
| Codeine | Shortness of Breath | Moderate | Active |
| Encounter | Performer | Location | Date |
|---|---|---|---|
| Pnuemonia | Dr Henry Seven | Community Health and Hospitals | 20120806 |
Father (deceased)
| Diagnosis | Age At Onset |
|---|---|
| Myocardial Infarction (cause of death) | 57 |
| Diabetes | 40 |
| Vaccine | Date | Status |
|---|---|---|
| Influenza virus vaccine | May 2012 | Completed |
| Tetanus and diphtheria toxoids | April 2012 | Completed |
| 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 |
| Planned Activity | Planned Date |
|---|---|
| Consultation with Dr George Potomac for Asthma | 20120820 |
| Chest X-ray | 20120826 |
| Sputum Culture | 20120820 |
| 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 |
Follow up with Dr George Potomac for Asthma
| Procedure | Date |
|---|---|
| Chest X-Ray | 8/7/2012 |
| Functional Condition | Effective Dates | Condition Status |
|---|---|---|
| Dependence on cane | November 1, 2008 | Active |
| Memory impairment | November 1, 2008 | Active |
| Result Type | Result Value |
|---|---|
| HGB | 10.2 g/dL |
| WBC | 12.3 10*3/uL |
| PLT | 123 10*3/uL |
| Social History Element | Description | Effective Dates |
|---|---|---|
| smoking | Former Smoker (1 pack per day | 20050501 to 20110227 |
| 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] |