Health Summary

Patient Isabella Jones
Date of birth May 1, 1947 Sex Female
Preferred Language eng
Race White Ethnicity Not Hispanic or Latino
Contact info 6401 Truxtun ave suite 220 Patient IDs 000000041
Bakersfield, CA 93009, USA 2.16.840.1.113883.3.13.300.1.1.2.1

Document Id 20141231081500 2.16.840.1.113883.19
Document Created: December 31, 2014, 08:15:00 +005
Care provision  from , to ,
Performer Dr. Henry Seven of Get Well Clinic
Author Henry Seven
Contact info Get Well Clinic
1002 HealthCare Dr.
Portland, OR 97005, USA
Tel: 555-555-1002
Encounter Id 547f6e28-c230-4bb6-9254-e22bc8cfd833 2.16.840.1.113883.19
Encounter Date  From August 6, 2012 to August 6, 2012
Encounter Location Get Well Clinic
Responsible party Henry Seven
Contact info 1002 HealthCare Dr.
Portland, OR 97005, USA
Tel: 555-555-1002
Entered by Mary McDonald
Contact info 1002 Healthcare Dr.
Portland, OR 97005, USA
Tel: 555-555-1002
Informant Henry Seven
Contact info 1002 HealthCare Dr.
Portland, OR 97005, USA
Tel: 555-555-1002
Informant Frank Jones, Husband
Legal authenticator Henry Seven signed at August 6, 2012
Contact info 1002 HealthCare Dr.
Portland, OR 97005, USA
Tel: 555-555-1002
Document Get Well Clinic
maintained by
Contact info 1002 HealthCare Dr.
Portland, OR 97005, USA
Tel: 555-555-1002

Table of Contents
Allergies, Adverse Reactions, Alerts
Medications
Medications Administered
Hospital Discharge Medications
Problems
Reason for Visit/Chief Complaint
Clinical Instructions/Patient Decision Aids
Laboratory Values/Results
Procedures
Vital Signs
Plan of Care, Goals and Instructions
 Assessments
Immunizations
Functional And Cognitive Status
Social History

Allergies, Adverse Reactions, Alerts

Allergy Substance Code CodeSystem Reaction Severity Status

Penicillin G benzathine 7982 RxNorm Hives Active

Codeine 2670 RxNorm Shortness of Breath Active

Aspirin 1191 RxNorm Hives Active

Medications

Medication Medication Start Fill

Medication Route Dose Status
Code CodeSystem Date Instructions
Clarithromycin 197517 RxNorm 2012- Oral 500 mg 1 TABLET twice Active
08-06 Daily for 7 days
Metoprolol 866924 RxNorm 2009- Oral 25 mg 1 TABLET once daily Active
Tartrate 05-01
Albuterol 573621 RxNorm 2007- Inhalation 0.09 mg 1 Active
01-03 INHALANT SOLUTION 2
puffs every 6 hours PRN
wheezing

Medications Administered

Start
Medication Code CodeSystem Route Dose/Frequency
Date
ALBUTEROL 0.09 MG/ACTUAT 573621 RxNorm 2012-08- Inhalation 0.09MG/ACTUAT inhalant solution,
[Proventil] 06 2 puffs once

Hospital Discharge Medications

Medication Direction Start Date Status Indications Fill Instuctions

No Discharge Medication

Problems

Alternate Alternate Start End

Problem Name Code CodeSystem Status
Code CodeSystem Date Date
Community acquired pneumonia 385093006 SNOMED- 2014- Active
(disorder) CT 12-26
Asthma(disorder) 195967001 SNOMED- 2014- Active
CT 12-26
Hypoxemia(disorder) 389087006 SNOMED- 2014- Active
CT 12-26

Reason for Visit/Chief Complaint

Mild Fever, 2 days

Chills, 2 days

Cough productive of greenish sputum 2 days

Clinical Instructions/Patient Decision Aids

Patient may continue to experience low grade fever and chills

Return to clinic or call 911 if you experience chest pain, shortness of breath, high fevers, or intructable vomiting/diarrhea

Laboratory Values/Results
 Test Test Code Code System Actual Result Date
HGB 30313-1 LOINC 14.2 g/dl 2014-12-30

WBC 33765-9 LOINC 7.6 (10^3/ul) 2014-12-30

PLT 26515-7 LOINC 220 (10^3/ul) 2014-12-30

HCT 20570-8 LOINC 45 % 2014-12-30

Procedures

Procedure Name Code CodeSystem Target Site Date of Procedure

Chest X-Ray, PA and Lateral Views 168731009 SNOMED-CT () 2012-08-06

Vital Signs

Vitals Date Value

Height 2014-12-26 69.685077 in

Weight 2014-12-26 194 lbs

Blood Pressure 2014-12-26 135/92 mmHg

BMI 2014-12-26 28.1

Plan of Care, Goals and Instructions

Planned Planned
Type Instructions Code CodeSystem
Activity DateTime
FUTURE Dr.Henry Seven, 1002 HealthCare Dr., 2015-
APPOINTMENT Portland, OR 97005 01-20
GOAL Smoking Resources and intructions provided during 225323000 SNOMED-
cessation visit CT
REFERRALS TO Dr. Penny Puffer, 555-555-1049, 1047 2012-
OTHER Healthcare Drive, Portland, OR 97005 on 08-20
PROVIDERS 8/20/2012 for a pulmonology consultation
DIAGNOSTIC Sputum 2012- 6460-0 LOINC
TESTS PENDING Culture 08-06
FUTURE Chest X-Ray 2012- 168731009 SNOMED-
SCHEDULED 08-13 CT
TESTS PENDING
FUTURE HGB 2012- 30313-1 LOINC
SCHEDULED 08-13
TESTS PENDING
FUTURE Colonoscopy 2012- 45378 CPT
SCHEDULED 09-22
TESTS PENDING

Assessments

1.  Pneumonia
2.  Asthma exacerbation

Immunizations

Vaccine Name Vaccine Code CodeSystem Date Status

Tetanus diphtheria adult 09 CVX 2007-01-04 Completed

Influenza virus vaccine 88 CVX 2009-11-01 Completed

 Vaccine Name Vaccine Code CodeSystem Date Status
Influenza virus vaccine 88 CVX 2010-09-10 Completed

Pneumococcal polysaccharide 33 CVX 2012-08-06 Completed

Functional And Cognitive Status

Type Condition Code Code System Date Status

FUNCTIONAL No Functional Status

COGNITIVE No Cognitive Status

Social History

Element Description Description Start Date End Date Code CodeSystem

Smoking Status Current every day smoker 1992-05-01 449868002 SNOMED-CT