170.315_b1_toc_inp_rn_r21_sample2 test data

Patient Jerry Gough, jr
Date of birth June 1, 1980
Sex Male
Race
Ethnicity
Contact info Primary Home:
1009 Amber Dr
Beaverton, OR 97006, US
Tel: +1(555)-331-1234
Patient IDs 121313344 2.16.840.1.113883.4.1
Document Id TT109 2.16.840.1.113883.19.5.99999.1
Document Created: July 22, 2015, 18:00:00, EST
Care provision Burn by Fire from July 22, 2015, 18:00:00, EST to July 22, 2015, 23:00:00 -5000
Performer (primary care physician) Dr Henry Seven of Community Health and Hospitals
Performer Mary McDonald
Author Dr Henry Seven
Contact info 1002 Healthcare Dr
Portland, OR 97266, US
Tel: +1(555)-555-1002
Encounter Id 9937012 2.16.840.1.113883.19
Encounter Date  From July 22, 2015, 18:00:00, EST to July 22, 2015, 23:00:00 -5000
Personal relationship Mr. Darren Gough
Contact info Primary Home:
1009 Amber Dr
Beaverton, OR 97006, US
Tel: +1(555)-332-1544
Personal relationship Ms Julane Gough
Contact info Primary Home:
1009 Amber Dr
Beaverton, OR 97006, US
Tel: +1(555)-332-1544
Entered by Mary McDonald
Contact info 1002 Healthcare Dr
Portland, OR 97266, US
Tel: +1(555)-555-1002
Signed Dr Henry Seven at July 22, 2015
Contact info 1002 Healthcare Dr
Portland, OR 97266, US
Tel: +1(555)-555-1002
Informant Henry Seven
Contact info 1002 Healthcare Dr
Portland, OR 97266, US
Tel: +1(555)-555-1002
Informant Julane Gough
Information recipient: Dr Henry Seven
Legal authenticator Dr Henry Seven signed at July 22, 2015
Contact info 1002 Healthcare Dr
Portland, OR 97266, US
Tel: +1(555)-555-1002
Document maintained by Community Health and Hospitals
Contact info 1002 Healthcare Dr
Portland, OR 97266, US
Tel: +1(555)-555-5000

Table of Contents

ALLERGIES AND ADVERSE REACTIONS

No Known Allergies

MEDICATIONS

No known Medications

Admission Medications

No Medications Administered

Discharge Medications

No Information

PROBLEMS

No known health problems

ENCOUNTERS

No Encounters

ADMISSION DIAGNOSIS

Skin burn

PROCEDURES

Procedure Date
Application of Dressing for burn July 22, 2015

MEDICAL EQUIPMENT

Patient has no history of implantable devices

IMMUNIZATIONS

No immunization history

VITAL SIGNS

Date / Time: June 22, 2015
Height 177 cm
Weight 88 kg
Blood Pressure 145/88 mm[Hg]
Date / Time: July 22, 2015
Body Temperature 99 degrees Fahrenheit

SOCIAL HISTORY

Social History Observation Description Dates Observed
Current Smoking Status Current every day July 22, 2015
Birth Sex Male July 22, 2015

RESULTS

Laboratory Test: None needed. Laboratory Values/Results: No Lab Result Information

ASSESSMENTS

The patient Mr Jerry Gough was found to have first degree burns and Dr Seven and his staff Mr Gough by cleaning the burn and dressing the burn and observed for couple of hours before discharging Mr Gough.

TREATMENT PLAN

Hand-off Communication:

Planned Care Start Date
Schedule an appointment with Dr Seven after 1 week for Follow up with Outpatient facility. July 29, 2015
Medication: Tylenol 500mg As needed

Goals Section

No goal information

Health Concerns

No Known Health Concerns on 07/22/2015

HOSPITAL DISCHARGE INSTRUCTIONS

  1. Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility.
  2. In case of fever, take Tylenol as advised in plan of treatment.

REASON FOR REFERRAL

No Reason for Referral data

MENTAL STATUS

No Mental Status information

FUNCTIONAL STATUS

No Functional Status information