170.315_b1_toc_amb_ccd_r21_sample1 test data

Patient	Alice Newman
Date of birth	May 1, 1970
Sex	Female
Race	White
Ethnicity	Not Hispanic or Latino
Contact info	Primary Home: 1357 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-777-1234
Patient IDs	444222222 2.16.840.1.113883.4.1

Document Id	TT989 2.16.840.1.113883.19.5.99999.1
Document Created:	June 22, 2015

Care provision	Fever from June 22, 2015, 10:00, EST to June 22, 2015, 10:30, EST
Performer (primary care physician)	Dr Albert Davis of Neighborhood Physicians Practice
Performer	Tracy Davis

Author	Dr. Davis Albert, Neighborhood Physicians Practice
Contact info	2472 Rocky place Beaverton, OR 97006, 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 22, 2015, 10:30, EST

Personal relationship	Mr Rick Holler
Contact info	Primary Home: 1357 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-723-1544
Personal relationship	Mr Matthew Newman
Contact info	Primary Home: 1357 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-723-1544

Entered by	Tracy Davis
Contact info	2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002

Signed	Dr Albert Davis at June 22, 2015
Contact info	2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002

Informant	Albert Davis
Contact info	2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002
Informant	Matthew Newman

Information recipient:

Dr Albert Davis

Legal authenticator	Dr Albert Davis signed at June 22, 2015
Contact info	2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002

Document maintained by	Neighborhood Physicians Practice
Contact info	Work Place: 2472 Rocky place Beaverton, OR 97006, US Tel: +1(555)-555-1002

ALLERGIES AND ADVERSE REACTIONS
MEDICATIONS
PROBLEMS
ENCOUNTERS
IMMUNIZATIONS
VITAL SIGNS
SOCIAL HISTORY
PROCEDURES
RESULTS
FUNCTIONAL STATUS
ASSESSMENTS
TREATMENT PLAN
Goals Section
Health Concerns Section
REASON FOR REFERRAL
MENTAL STATUS

ALLERGIES AND ADVERSE REACTIONS

Substance	Reaction	Severity	Status
Penicillin G benzathine	Hives	Moderate	Active

MEDICATIONS

Medication	Directions	Start Date
Ceftriaxone 100MG/ML	Two Times daily	June 22, 2015
Tylenol 500mg	For 10 days As needed	June 22, 2015

PROBLEMS

Active Concerns

Problem #1
- Essential hypertension (Disorder)
Problem #2
- Severe Hypothyroidism (Disorder)
Problem #4
- Fever (finding)

Resolved Concerns

Problem #5
- Overweight (finding)

ENCOUNTERS

Encounter Diagnosis	Location	Date
Fever	Neighborhood Physicians Practice	June 22, 2015 at 10am EST

IMMUNIZATIONS

Vaccine	Date	Status
Influenza Virus Vaccine	May 10, 2014	Completed
Tetanus and diphtheria toxoids	January 4, 2012	Completed
influenza, intradermal, quadrivalent, preservative free	June 22, 2015	Refused by Patient

VITAL SIGNS

Date / Time:	June 22, 2015
Height	177 cm
Weight	88 kg
Blood Pressure	145/88
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	May 1, 2005 - February 27, 2011
Current Smoking Status	Current every day	June 22, 2015

PROCEDURES

Procedure	Date
Nebulizer Therapy	June 22, 2015
Introduction of cardiac pacemaker system via vein	October 5, 2011

RESULTS

Result Type	Result Value	Relevant Reference Range	Interpretation	Date
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	50mg/dl	Neg		06/22/2015
Ketones [Mass/Volume] in urine by test strip	Negative	Negative		06/22/2015
Protein[Mass/Volume] in urine by test strip	100mg/dl	negative		06/22/2015

FUNCTIONAL STATUS

Functional Category	Effective Dates
Dependence on Cane	May 01, 2005

The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day.

TREATMENT PLAN

Hand-off Communication:

Planned Care	Start Date
Urinanalysis macro (dipstick) panel	June 22, 2015
Get an EKG done on 6/23/2015.	June 23, 2015
Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure.	June 23, 2015
Take Clindamycin 300mg three times a day as needed if pain does not subside.	June 23, 2015 three times a day as needed
Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015.	July 7, 2015

Goals Section

Goal	Value	Date
Get rid of intermittent fever that is occurring every few weeks (Visual Inspection)	N/A	June 23, 2015
Need to gain more energy to do regular activities (Visual Inspection)	N/A	June 23, 2015

Health Concerns Section

Observation	Status	Date
Chronic Sickness exhibited by patient	Active	June 22, 2015

Concern	Status	Date
Documented HyperTension problem	Active	June 22, 2015
Documented HypoThyroidism problem	Active	June 22, 2015
Watch Weight of patient	Active	June 22, 2015

REASON FOR REFERRAL

Ms Alice Newman is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia.

MENTAL STATUS

Status	Date
Amnesia	May 05, 2005