170.315_b1_toc_inp_rn_r21_sample1 test data

Patient Michelle Marshall
Date of birth June 1, 1970
Sex Female
Race White
Ethnicity Not Hispanic or Latino
Contact info Primary Home:
1010 Amber Dr
Beaverton, OR 97266, US
Tel: +1(555)-333-1234
Patient IDs 122323345 2.16.840.1.113883.4.1
Document Id TT110 2.16.840.1.113883.19.5.99999.1
Document Created: June 22, 2015
Care provision Anemia from June 22, 2015 to June 24, 2015
Performer (primary care physician) Dr Henry Seven of Community Health and Hospitals
Performer Mary McDonald
Author Dr Henry Seven
Contact info 1002 Healthcare Dr
Beaverton, OR 97266, US
Tel: +1(555)-555-1002
Encounter Id 9937012 2.16.840.1.113883.19
Encounter Date  From June 22, 2015, 10:00, EST to June 24, 2015
Personal relationship Mr Kerry Grant
Contact info Primary Home:
1010 Amber Dr
Beaverton, OR 97266, US
Tel: +1(555)-334-1544
Personal relationship Mr James Marshall
Contact info Primary Home:
1010 Amber Dr
Beaverton, OR 97266, US
Tel: +1(555)-334-1544
Entered by Mary McDonald
Contact info 1002 Healthcare Dr
Beaverton, OR 97266, US
Tel: +1(555)-555-1002
Signed Dr Henry Seven at June 22, 2015
Contact info 1002 Healthcare Dr
Beaverton, OR 97266, US
Tel: +1(555)-555-1002
Informant Henry Seven
Contact info 1002 Healthcare Dr
Beaverton, OR 97266, US
Tel: +1(555)-555-1002
Informant James Marshall
Information recipient: Dr Henry Seven
Legal authenticator Dr Henry Seven signed at June 22, 2015
Contact info 1002 Healthcare Dr
Beaverton, OR 97266, US
Tel: +1(555)-555-1002
Document maintained by Community Health and Hospitals
Contact info Work Place:
1002 Healthcare Dr
Beaverton, OR 97266, US
Tel: +1(555)-555-1002

Table of Contents

ALLERGIES AND ADVERSE REACTIONS

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

MEDICATIONS

Medication Directions Start Date
Ceftriaxone 100MG/ML Two times daily June 22, 2015
Vantin Two times daily June 22, 2015
Tylenol 500mg As needed June 22, 2015
Darbepoetin 0.5 MG/ML Once a week June 22, 2015
Clindamycin 300mg Three times daily June 23, 2015
Torsemide 20mg Daily June 23, 2015
Levothyroxine Sodium Daily June 23, 2015
Prednisolone 10mg Daily June 23, 2015
FenoFibric Acid 35mg At the hour of sleep June 24, 2015
Mycophenolic Acid 360mg Two times daily June 24, 2015
Everolimus 0.5mg Two times daily June 24, 2015
Ciprofloxacin 2mg/ml Three times daily June 25, 2015

Discharge Medications

No Information

PROBLEMS

Active Concerns

Resolved Concerns

ENCOUNTERS

Encounter Diagnosis Location Date
Anemia in Chronic Kidney Disease Community Health and Hospitals June 22, 2015 at 10:00 am EST

ADMISSION DIAGNOSIS

Anemia

PROCEDURES

Procedure Date
Bronchoscopy June 22, 2015
Chest X-Ray, PA and Lateral Views 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

IMMUNIZATIONS

Vaccine Date Status Series number
Influenza Virus Vaccine May 10, 2014 Completed N/A
Tetanus and diphtheria toxoids January 4, 2012 Completed N/A
influenza, intradermal, quadrivalent, preservative free June 22, 2015 Refused N/A

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, ??-??/day May 1, 2005 - February 27, 2011
Current Smoking Status Current every day June 22, 2015
Birth Sex Female June 22, 2015

RESULTS

Result Type Result Value Relevant Reference Range Interpretation Date
HGB 10.2 g/dL 06/22/2015
WBC 12.3 (10*3/uL) N/A - 500,000 06/22/2015
PLT 123 (10*3/uL) 06/22/2015
Everolimus Blood 10 ng/mL 3.0-8.0 ng/ml 06/22/2015
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 Normal 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

MENTAL STATUS

Status Date
Amnesia May 05, 2005

ASSESSMENTS

The patient was found to have Anemia and Dr Seven and his staff diagnosed the condition and treated Ms Alice for Anemia during the 2 day stay at Community Health Hospitals. Ms Alice recovered from Anemia during the stay and is being discharged in a stable condition. If there is fever greater than 101.5 F or onset of chest pain/breathlessness the patient is advised to contact emergency.

TREATMENT PLAN

Hand-off Communication:

Planned Care Start Date
Urinanalysis macro (dipstick) panel June 29, 2015
Immunosuppressive therapy July 1, 2015
Schedule an appointment with Dr Seven after 1 week for Follow up with Outpatient facility for Immunosuppressive therapy. July 1, 2015

Goals Section

Goal Value Date
Need to gain more energy to do regular activities (Visual Inspection) N/A June 23, 2015
Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit June 23, 2015

Health Concerns Section

Observation Status Date
Chronically ill Active June 22, 2015

Concern Status Date
HyperTension problem concern Active June 22, 2015
HypoThyroidism problem concern Active June 22, 2015
Anemia problem concern Active June 22, 2015

Related observation Date
Vital Sign Weight Observation June 22, 2015

HOSPITAL DISCHARGE INSTRUCTIONS

  1. Diet: Diabetic low salt diet
  2. Medications: Take prescribed medications as advised.
  3. Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility for Immunosuppression treatment.
  4. For Fever of > 101.5 F, or onset of chest pain/breathlessness contact Emergency.

REASON FOR REFERRAL

No Reason for Referral data