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+ | Name | +Dates | +Details | +
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+ | Name | +Dates | +Details | +
|---|---|---|
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+ + |
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+
+ | Date | +Test | +Result | +Details | +
|---|---|---|---|
| + | + | + | + |
|
+ + |
+
+ |
+
+ |
+
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+
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+
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+
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| Date | +Description | +Value | +Details | +
|---|---|---|---|
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+ + |
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+ |
+
+ |
+ + |
| + | + | + | + |
| Name | +Dates | +Details | +
|---|---|---|
|
+ |
+
+ + |
+
+ |
+
|
+ |
+
+ + |
+
+ |
+
|
+ + + + |
+
+ + |
+
+
+
+
+ |
+ + + + |
+
+ + |
+
+
+
+
+ | Directive | +Description | +Verification | +Supporting Document(s) | +
|---|---|---|---|
| Resuscitation status | +Do not resuscitate | +Dr. Patricia Primary, Feb 19, 2011 | +
+ |
+
+
+ | Substance | +Reaction | +
|---|---|
| Penicillin | +Nausea | +
| Codeine | +Wheezing | +
| Encounter | +Performer | +Location | +Date | +
|---|---|---|---|
| Checkup Examination | +Performer Name | +Community Urgent Care Center | +September 27, 2012 at 1:00pm | +
+
+
+
+
+
+
+
+ | Diagnosis | +Age At Onset | +
|---|---|
| Myocardial Infarction (cause of death) | +57 | +
| Diabetes | +40 | +
+
+
+
+
+
+
+
+
+ | Functional Category | +Effective Dates | +Results of Evaluation | +
|---|---|---|
| Functional Assessment | +March 11, 2013 | +Independent Walking | +
| ADL/IADL: Bathing | +March 11,2013 | +Independent | +
| Vaccine | +Date | +Status | +Series number | +
|---|---|---|---|
|
+ |
+ Nov 1999 | +Completed | +N/A | +
|
+ |
+ Dec 1998 | +Completed | +N/A | +
|
+ |
+ Dec 1998 | +Completed | +N/A | +
|
+ |
+ 1997 | +Refused | +N/A | +
| Hepatitis B | +Aug 1, 2013 | +Completed | +3rd | +
+
+
+
+
+
+
+
+
+
+ Implants
+
+
+ Cardiac Pacemaker
+
+
+ Upper GI Prosthesis
+
+
+ Upper GI Prosthesis
+
+
+
+
+
+ | Medication | +Directions | +Start Date | +Status | +Indications | +Fill Instructions | +
|---|---|---|---|---|---|
| Proventil 0.09 MG/ACTUAT inhalant solution | +2 puffs q6 hours PRN wheezing | +Jan 3, 2011 | +Active | +Asthma | +Generic Substitition Allowed | +
| Atenolol 25 MG Oral Tablet | +1 every 12 hours Orally | +Mar 18, 2012 | +Active | +Hypertension | +-none- | +
+
+
+
+
+
+
+
+
+ | Payer name | +Policy type / Coverage type | +Policy ID | +Covered party ID | +Policy Holder | +
|---|---|---|---|---|
| Good Health Insurance | +Extended healthcare / Family | +Contract Number | +1138345 | +Patient's Mother | +
+
+
+ | Planned Care | +Start Date | +Patient Provider Rating | +Provider Provider Rating | +Provider | +Patient Support/Caregiver | +
|---|---|---|---|---|---|
| Procedure: Colonoscopy | +June 15, 2013 | +1st, Medium | +3rd, Medium | ++ | Caregiver: Mother | +
| Medication: Heparin 0.25 ml pre-filled syringe | +July 12, 2013 | ++ | First, Medium | +Third, Medium | +Caregiver: Mother | +
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ | Procedure | +Date | +
|---|---|
| Colonic polypectomy | +1998 | +
+
+
+
+
+
+
+
+
+
+
+
+ | Result Type | +Result Value | +Relevant Reference Range | +Interpretation | +Date | +
|---|---|---|---|---|
| Hemoglobin | +13.2 g/dL | +Normal range for women is 12.0 to 15.5 grams per deciliter | +Normal | +03/19/2008 | +
| Leukocytes | +6.7 10*9/L | +Normal white blood cell count range 3.5-10.5 billion cells/L | +Normal | +03/19/2008 | +
| Platelets | +123 10*9/L | +Normal white blood cell count range 3.5-10.5 billion cells/L | +Low | +03/19/2008 | +
| Hematocrit | +35.3 % | +Normal hematocrit range for female: 34.9-44.5 percent | +Normal | +03/19/2008 | +
| Erythrocytes | +4.21 10*12/L | +Normal red blood cell count range 3.90-5.03 trillion cells/L | +Normal | +03/19/2008 | +
| Urea nitrogen, Serum | +Pending | +Pending | +Pending | +March 20, 2008 | +
| Social History Observation | +Description | +Dates Observed | +
|---|---|---|
| Current Smoking Status | +Former smoker | +September 10, 2012 | +
| Tobacco Use | +Moderate cigarette smoker, 10-19/day | +February, 2009 - February, 2011 | +
| Alcoholic drinks per day | +12 | +Since February, 2012 | +
| Date / Time: | +Sept 10, 2012 | +Sept 1, 2011 | +
|---|---|---|
| Height | +177 cm | +177 cm | +
| Weight | +86 kg | +88 kg | +
| Blood Pressure | +132/88 | +128/80 | +
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Vaccination
+
+
+ | Social History Observation | +Description | +Dates Observed | +
|---|---|---|
| Current Smoking Status | +Current every day | +July 22, 2015 | +
| Birth Sex | +Male | +July 22, 2015 | +
| Description | +Date and Time (Range) | +Status | +
|---|---|---|
| Laparoscopic appendectomy | +03 Feb 2014 09:22am- 03 Feb 2014 11:15am | +Completed | +
| Electrocardiogram (12-Lead) | +29 Mar 2014 09:15am | +Completed | +
| Individual Counseling For Medical Nutrition | +29 Mar 2014 10:45am | +Completed | +
+ Laparoscopic appendectomy
+
+
+ Electrocardiogram (12-Lead)
+
+
+ Individual Counseling For Medical Nutrition
+
+ | Name | +Actual Result | +Date | +
|---|---|---|
| CBC with Ordered Manual Differential panel - Blood | ++ | 8/6/2012 | +
|
+ |
+
+ Pending | +8/6/2012 11:45am | +
| Social History Observation | +Description | +Dates Observed | +
|---|---|---|
| Current Smoking Status | +
+ |
+ September 10, 2012 11:45am | +
| Date | +Blood Pressure | +Pulse | +Temperature | +Respiratory Rate | +Height | +Weight | +BMI | +SpO2 | +
|---|---|---|---|---|---|---|---|---|
| 05/20/2014 7:36pm | + +
+ |
+ 80 /min | +37.2 C | +18 /min | +170.2 cm | +108.8 kg | +37.58 kg/m2 | +98% | +
| Concern | +Status | +Date | +
|---|---|---|
| Current every day smoker | +Active | +Concern from June 16, 2013 | +
| Respiratory insufficiency | +Completed | +Concern from June 13, 2013 | +
| Pneumonia | +Completed | +June 16, 2013 | +
| Related observation | +Date | +
|---|---|
| Productive cough | +June 15, 2013 | +
| Risk | +Status | +Effective Date | +
|---|---|---|
| Malignant neoplastic disease | +Active | +June 16, 2013 | +
| Goal | +Value | +Date | +
|---|---|---|
| Pulse oximetry | +92% | +September 2, 2013 | +
| Planned Intervention | +Status | +Date | +
|---|---|---|
| Elevate head of bed | +active | +September 2, 2013 | +
| Oxygen administration by nasal cannula | +active | +September 1, 2013 | +
| pulse oximetry monitoring | +active | +September 3, 2013 | +
| Completed Intervention | +Status | +Date | +
|---|---|---|
| Elevate head of bed | +completed | +August 1, 2013 | +
| Item | +Outcome | +Date | +
|---|---|---|
| Pulse oximetry | +95% | +August 6, 2013 | +
+
+
+
+
+ | Substance | +Reaction | +
|---|---|
| Penicillin | +Nausea | +
| Codeine | +Wheezing | +
| Functional Category | +Effective Dates | +Results of Evaluation | +
|---|---|---|
| Functional Assessment | +July 31, 2013 | +Independent Walking | +
| ADL/IADL: Bathing | +July 31,2013 | +Independent | +
| Medication | +Directions | +Start Date | +Status | +Indications | +Monitored by | +
|---|---|---|---|---|---|
| Proventil 0.09 MG/ACTUAT inhalant solution | +2 puffs q6 hours PRN wheezing | +Jan 3, 2013 | +Active | +Asthma | +Penny Puffer, MD | +
| Atenolol 25 MG Oral Tablet | +1 every 12 hours Orally | +Mar 18, 2013 | +Active | +Hypertension | ++ |
| Mental Status Findings | +Effective Dates | +Condition Status | +
|---|---|---|
| Mental Function | +July 31, 2013 | +Impaired | +
| Mental Status | +July 31, 2013 | +Aggressive Behavior | +
| Mental Function | +July 31, 2013 | +Difficulty understanding own emotions | +
| Mental Function | +July 31, 2013 | +Difficulty communicating Thoughts | +
+
+ Nutritional Status
+
+ | Planned Care | +Start Date | +Patient Provider Rating | +Provider Provider Rating | +Provider | +Patient Support/Caregiver | +
|---|---|---|---|---|---|
| Encounter for Check-up | +October 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | +Dr. James Case | ++ |
| Care Goal: Weight loss from baseline weight 10% | +October 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | ++ | + |
| Nutrition Recommendation: Education | +July 31, 2013 | ++ | + | + | + |
+
+ | Result Type | +Result Value | +Relevant Reference Range | +Interpretation | +Date | +
|---|---|---|---|---|
| Hemoglobin | +13.2 g/dL | +Normal range for women is 12.0 to 15.5 grams per deciliter | +Normal | +July 31, 2013 | +
| Leukocytes | +6.7 10*9/L | +Normal white blood cell count range 3.5-10.5 billion cells/L | +Normal | +July 31, 2013 | +
| Platelets | +123 10*9/L | +Normal white blood cell count range 3.5-10.5 billion cells/L | +Low | +July 31, 2013 | +
| Hematocrit | +35.3 % | +Normal hematocrit range for female: 34.9-44.5 percent | +Normal | +July 31, 2013 | +
| Erythrocytes | +4.21 10*12/L | +Normal red blood cell count range 3.90-5.03 trillion cells/L | +Normal | +July 31, 2013 | +
| Urea nitrogen, Serum | +Pending | +Pending | +Pending | +July 31, 2013 | +
| Date / Time: | +Sept 10, 2012 | +Sept 1, 2011 | +
|---|---|---|
| Height | +177 cm | +177 cm | +
| Weight | +86 kg | +88 kg | +
| Blood Pressure | +132/88 | +128/80 | +
+
+
+
+
+
+
+
+
+
+
+
+
+
+ | Substance | +Reaction | +Severity | +Status | +
|---|---|---|---|
| Penicillin | +
+ |
+
+ |
+ Active | +
| Codeine | +
+ |
+
+ |
+ Active | +
| Eggs | +
+ |
+
+ |
+ Active | +
+
+
+
+
+
+
+
+
+
+
+
+ | Medication | +Instructions | +Dosage | +Effective Dates (start - stop) | +Status | +
|---|---|---|---|---|
|
+ |
+
+ |
+
+ |
+ Sep-16-2014 - | +Active | +
+
+
+
+ | Diagnosis | +Age At Onset | +
|---|---|
| Myocardial Infarction (cause of death) | +57 | +
| Diabetes | +6 | +
+
+ | Functional Status Finding | +Observation Date | +Condition Status | +
|---|---|---|
| Dyspnea | +February 2007 | +Active | +
| Gastroenterology | +
| Cardiology | +
| Dietitian | +
| Laboratory Information | +Chemistries and drug levels | +
|---|---|
| Potasium | +4.0 | +
| NA (135-145meq/l) | +140 | +
| Other Tests | +Results | +
|---|---|
| Abdominal CT | +Clear evidence of appendicitis. | +
| Vaccine | +Date | +Status / Notes | +
|---|---|---|
|
+ |
+ Sep 1, 2014 | +Completed. |
+
|
+ |
+ Sep 1, 2014 | +Patient Refused | +
+ Influenza virus vaccine
+
+
+ Tetanus and diphtheria toxoids - preservative free
+
+ | Planned Activity | +Planned Date | +
|---|---|
| Colonoscopy | +Oct 12, 2014 | +
| Name | +Dates | +Status | +
|---|---|---|
| Dark stools | +
+ |
+ Active | +
| Appendicitis | +
+ |
+ Active | +
| Description | +Date and Time (Range) | +Status | +
|---|---|---|
| Laparoscopic appendectomy | +(10 Sep 2014 09:22am- 10 Sep 2014 11:15am) | +Completed | +
+
+
+
+ | Date / Time: | +Sept 16, 2014 8:45am | +
|---|---|
| Height | +
+ |
+
| Weight | +
+ |
+
| Blood Pressure | +
+ |
+
| Substance | +Reaction | +Severity | +Status | +
|---|---|---|---|
| ALLERGENIC EXTRACT, PENICILLIN | +
+ |
+
+ |
+ Inactive | +
| Codeine | +
+ |
+
+ |
+ Active | +
| Aspirin | +
+ |
+
+ |
+ Active | +
+
+
+
+
+
+
+
+
+
+
+
+ | Diagnosis | +Age At Onset | +
|---|---|
| Myocardial Infarction (cause of death) | +57 | +
| Diabetes | +40 | +
+
+ | Vaccine | +Date | +Status | +
|---|---|---|
|
+ |
+ Nov 1999 | +Completed | +
|
+ |
+ Dec 1998 | +Completed | +
|
+ |
+ Dec 1998 | +Completed | +
|
+ |
+ 1997 | +Refused | +
+ Influenza virus vaccine
+
+
+ Influenza virus vaccine
+
+
+ Influenza virus vaccine
+
+
+ Tetanus and diphtheria toxoids - preservative
+ free
+
+ | Medication | +Directions | +Start Date | +Status | +Indications | +Fill Instructions | +
|---|---|---|---|---|---|
|
+ |
+ 0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing | +20070103 | +Active | +Pneumonia (233604007 SNOMED CT) | +Generic Substitition Allowed | +
+
+
+
+
+
+
+
+
+
+
+
+ | Planned Activity | +Planned Date | +
|---|---|
| Colonoscopy | +20120512 | +
+ | Procedure | +Date | +
|---|---|
|
+ |
+ 1998 | +
+
+
+
+
+
+
+
+
+
+
+
+ | LABORATORY INFORMATION | +|
| Chemistries and drug levels | +|
|
+ |
+ 13.2 | +
|
+ |
+ 6.7 | +
|
+ |
+ 123 (L) | +
| Liver Functions and Other Laboratory Values | +|
| ALT (SGPT) | +31.0 | +
| AST (SGOT) | +18.0 | +
| GGT | +28.0 Alk | +
| Phos | +86.0 | +
| Total Bili | +0.1 | +
| Albumin | +3.2 | +
| Blood Count | +|
| White Count | +7.7 | +
| Platelets | +187.0 | +
| Hematocrit | +23.7 | +
| Hemoglobin | +8.1 | +
| ELECTROCARDIOGRAM (EKG) INFORMATION | +|
| EKG | +Sinus rhythm without acute changes | +
+
+
+ | Social History Element | +Description | +Effective Dates | +
|---|---|---|
|
+ |
+ Former smoke | +20050501 to 200902271300-0500 | +
|
+ |
+ 5 years of working with asbestos | +20050501-20100431 | +
|
+ |
+ 0 | +20050501 - | +
+
+
+
+
+
+
+
+ | Date / Time: | +Nov 14, 1999 | +April 7, 2000 | +
|---|---|---|
| Height | +
+ |
+
+ |
+
| Weight | +
+ |
+
+ |
+
| Blood Pressure | +
+ |
+
+ |
+
+
+
+
+
+
+
+ | Planned Activity | +Planned Date | +
|---|---|
| Colonoscopy | +20120512 | +
+
+
+
+
+
+ | Name | +Dates | +Location/Qualifier | +Status | +
|---|---|---|---|
| Below Knee Amputation | +
+ |
+ Left | +Active | +
| Community Acquired Pneumonia | +Onset: February 27 2014 | +Active | +
+
+
+
+
+
+
+
+ Vaccination
+
+
+ | Social History Observation | +Description | +Dates Observed | +
|---|---|---|
| Current Smoking Status | +Current every day | +July 22, 2015 | +
| Birth Sex | +Male | +July 22, 2015 | +
| Group Description | +Code System | +Code | +Code Description | +Severity | +Susceptibility | +Date and Time | +Status | +
|---|---|---|---|---|---|---|---|
| Allergy to Eggs | +UNII | +291P45F896 | +Very susceptible | +03-31-2010 10:00:00 | +Active | +||
| + | ICD-9-CM | +V15.03 | +Allergy to eggs | ++ | + | + | + |
| Codeine | +NDF-RT | +N0000006691 | +Susceptible | +03-31-2010 10:00:00 | +Active | +||
| Fosfomycin | +RxNorm | +808917 | +Very susceptible | +03-31-2010 10:00:00 | +Active | +
+
+ Allergy to Eggs + Eggs
+
+
+
+
+
+ Codeine + Codeine
+
+
+
+
+
+ Fosfomycin + Fosfomycin 33.3 MG/ML Oral Suspension
+
+
+
+ | Group Description | +Code System | +Code | +Code Description | +Date and Time | +Status | +
|---|---|---|---|---|---|
| Encounter Outpatient | +CPT | +99213 | +03-31-2010 10:00:00 | +Performed | +|
| + | ICD-9-CM | +V70.0 | +Routine general medical examination at a health care facility | ++ | + |
| Encounter ED | +CPT | +99281 | +04-30-2010 10:00:00 | +Performed | +|
| Encounter Inpatient Discharge | +CPT | +99238 | +05-28-2010 10:00:00 | +Performed | +|
| Encounter Outpatient | +CPT | +99213 | +06-25-2010 10:00:00 | +Performed | +|
| + | ICD-9-CM | +V70.0 | +Routine general medical examination at a health care facility | ++ | + |
| Encounter Outpatient | +CPT | +99213 | +10-24-2010 10:00:00 | +Performed | +|
| + | ICD-9-CM | +V70.0 | +Routine general medical examination at a health care facility | ++ | + |
+
+ Encounter Outpatient + Encounter Outpatient
+
+
+
+
+ Encounter ED + Encounter ED
+
+
+
+
+ Encounter Inpatient Discharge + Encounter Inpatient Discharge
+
+
+
+
+ Encounter Outpatient + Encounter Outpatient
+
+
+
+
+ Encounter Outpatient + Encounter Outpatient
+
+
+ | Group Description | +Code System | +Code | +Code Description | +Date and Time | +Status | +
|---|---|---|---|---|---|
| Influenza Vaccine | +CVX | +135 | +10-24-2010 10:00:00 | +Completed | +|
| Pneumococcal Vaccine all ages | +CVX | +100 | +10-24-2010 10:00:00 | +Completed | +|
| + | CPT | +90669 | +Pneumococcal vacc, ped<5 | ++ | + |
+
+ Influenza Vaccine + Influenza Vaccine
+
+
+
+
+ Pneumococcal Vaccine all ages + Pneumococcal Vaccine all ages
+
+
+ | Group Description | +Code System | +Code | +Code Description | +Date and Time | +Status | +
|---|---|---|---|---|---|
| Antidiabetics | +RxNorm | +744863 | +03-31-2010 10:00:00 | +Active | +|
| Antihypertensive combinations | +RxNorm | +858828 | +03-31-2010 10:00:00 | +Active | +|
| Antiplatelets | +RxNorm | +243670 | +03-31-2010 10:00:00 | +Active | +|
| Beta Blocker Therapy | +RxNorm | +866924 | +03-31-2010 10:00:00 | +Active | +|
| Statins | +RxNorm | +617314 | +03-31-2010 10:00:00 | +Active | +|
| ACE inhibitors | +RxNorm | +314076 | +10-24-2010 10:00:00 | +Active | +|
| Antidiabetics | +RxNorm | +744863 | +10-24-2010 10:00:00 | +Active | +|
| Statins | +RxNorm | +617314 | +10-24-2010 10:00:00 | +Active | +
+
+ Antidiabetics + exenatide 0.25 MG/ML Injectable Solution
+
+
+
+
+ Antihypertensive combinations + Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet
+
+
+
+
+ Antiplatelets + Aspirin 81 MG Oral Tablet
+
+
+
+
+ Beta Blocker Therapy + Metoprolol Tartrate 25 MG Oral Tablet
+
+
+
+
+ Statins + atorvastatin 10 MG Oral Tablet [Lipitor]
+
+
+
+
+ ACE inhibitors + Lisinopril 10 MG Oral Tablet
+
+
+
+
+ Antidiabetics + exenatide 0.25 MG/ML Injectable Solution
+
+
+
+
+ Statins + atorvastatin 10 MG Oral Tablet [Lipitor]
+
+
+ | Group Description | +Code System | +Code | +Code Description | +Date and Time | +Status | +
|---|---|---|---|---|---|
| Coronary Artery Disease No MI | +SNOMED-CT | +53741008 | +03-31-2010 10:00:00 | +Active | +|
| + | ICD-10-CM | +I25.1 | +Atherosclerotic heart disease of native coronary artery | ++ | + |
| + | ICD-9-CM | +414.01 | +Coronary atherosclerosis of native coronary artery | ++ | + |
| Diabetes | +SNOMED-CT | +44054006 | +03-31-2010 10:00:00 | +Active | +|
| + | ICD-10-CM | +E11.9 | +Type 2 diabetes mellitus without complications | ++ | + |
| + | ICD-9-CM | +250.00 | +Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled | ++ | + |
| Hypertension | +SNOMED-CT | +59621000 | +03-31-2010 10:00:00 | +Active | +|
| + | ICD-10-CM | +I10 | +Essential (primary) hypertension | ++ | + |
| + | ICD-9-CM | +401.9 | +Unspecified essential hypertension | ++ | + |
| Myocardial Infarction | +SNOMED-CT | +304914007 | +05-28-2010 10:00:00 | +Active | +|
| + | ICD-10-CM | +I21.3 | +ST elevation (STEMI) myocardial infarction of unspecified site | ++ | + |
| + | ICD-9-CM | +410.90 | +Acute myocardial infarction of unspecified site, episode of care unspecified | ++ | + |
| Group Description | +Code System | +Code | +Code Description | +Date and Time | +Status | +
|---|---|---|---|---|---|
| Counseling For Nutrition | +CPT | +97802 | +03-31-2010 10:00:00 | +Performed | +|
| + | HCPCS | +S9470 | +Nutritional counseling, diet | ++ | + |
| + | ICD-10-CM | +Z00.8 | +Encounter for other general examination | ++ | + |
| + | ICD-9-CM | +V65.3 | +Dietary surveillance and counseling | ++ | + |
| Counseling For Physical Activity | +HCPCS | +S9451 | +03-31-2010 10:00:00 | +Performed | +|
| + | ICD-10-CM | +Z71.3 | +Dietary counseling and surveillance | ++ | + |
| + | ICD-9-CM | +V65.41 | +Exercise counseling | ++ | + |
| X-ray Study | +CPT | +76499 | +05-23-2010 10:00:00 | +Performed | +|
| + | SNOMED-CT | +363680008 | +Radiographic imaging procedure (procedure) | ++ | + |
| LVF Assessment | +CPT | +93543 | +05-24-2010 10:00:00 | +Performed | +|
| Cardiac Monitoring | +SNOMED-CT | +23852006 | +05-25-2010 10:00:00 | +Performed | +|
| dietary consultation order | +SNOMED-CT | +103699006 | +05-27-2010 10:00:00 | +Performed | +|
| Foot Exam | +SNOMED-CT | +401191002 | +06-25-2010 10:00:00 | +Performed | +|
| Eye Exam | +CPT | +92012 | +07-30-2010 10:00:00 | +Performed | +|
| + | HCPCS | +S0621 | +Routine ophthalmological exa | ++ | + |
| + | ICD-9-CM | +95.03 | +Extended ophthalmologic work-up | ++ | + |
| + | SNOMED-CT | +36228007 | +Ophthalmic examination and evaluation | ++ | + |
| Foot Exam | +SNOMED-CT | +401191002 | +10-24-2010 10:00:00 | +Performed | +
+
+ Counseling For Nutrition + Medical nutrition, indiv, in
+
+
+
+
+ Counseling For Physical Activity + Exercise class
+
+
+
+
+ X-ray Study + Radiographic procedure
+
+
+
+
+ LVF Assessment + Injection for heart x-rays
+
+
+
+
+ Cardiac Monitoring + Cardiac monitoring
+
+
+
+
+ dietary consultation order + Patient referral to dietitian
+
+
+
+
+ Foot Exam + Diabetic foot examination
+
+
+
+
+ Eye Exam + Eye exam established pat
+
+
+
+
+ Foot Exam + Diabetic foot examination
+
+
+ | Group Description | +Code System | +Code | +Code Description | +Value | +Unit | +Reference Range | +Date and Time | +Status | +
|---|---|---|---|---|---|---|---|---|
| HbA1c test | +LOINC | +4548-4 | +7 | +% | +4-5.6% | +03-31-2010 10:00:00 | +Completed | +|
| + | CPT | +83036 | +Glycated hemoglobin test | ++ | + | + | + | + |
| + | SNOMED-CT | +43396009 | +Hemoglobin A1c measurement | ++ | + | + | + | + |
| High Density Lipoprotein (HDL) | +LOINC | +14646-4 | +63 | +mg/dL | +>=40 mg/dL | +03-31-2010 10:00:00 | +Completed | +|
| + | CPT | +83701 | +Lipoprotein bld, hr fraction | ++ | + | + | + | + |
| + | SNOMED-CT | +28036006 | +High density lipoprotein cholesterol measurement | ++ | + | + | + | + |
| Low Density Lipoprotein (LDL) | +LOINC | +2089-1 | +150.2 | +mg/dL | +<130 mg/dL (calc) | +03-31-2010 10:00:00 | +Completed | +|
| + | CPT | +83721 | +Assay of blood lipoprotein | ++ | + | + | + | + |
| + | SNOMED-CT | +113079009 | +Low density lipoprotein cholesterol measurement | ++ | + | + | + | + |
| Total Cholesterol | +LOINC | +2093-3 | +251 | +mg/dL | +125-200 mg/dL | +03-31-2010 10:00:00 | +Completed | +|
| + | CPT | +82465 | +Assay, bld/serum cholesterol | ++ | + | + | + | + |
| + | SNOMED-CT | +121868005 | +Total cholesterol measurement | ++ | + | + | + | + |
| Triglycerides | +LOINC | +12951-0 | +189 | +mg/dL | +10-39 years: 55-110 mg/dL | 40-59 years: 70-150 mg/dL | >60 years: 80-150 mg/dL | Therapeutic Target: <100 mg/dL | +03-31-2010 10:00:00 | +Completed | +|
| + | CPT | +84478 | +Assay of triglycerides | ++ | + | + | + | + |
| + | SNOMED-CT | +14740000 | +Triglycerides measurement | ++ | + | + | + | + |
| HbA1c test | +LOINC | +4548-4 | +6.6 | +% | +4-5.6% | +07-25-2010 10:00:00 | +Completed | +|
| + | CPT | +83036 | +Glycated hemoglobin test | ++ | + | + | + | + |
| + | SNOMED-CT | +43396009 | +Hemoglobin A1c measurement | ++ | + | + | + | + |
| HbA1c test | +LOINC | +4548-4 | +6.7 | +% | +4-5.6% | +10-24-2010 10:00:00 | +Completed | +|
| + | CPT | +83036 | +Glycated hemoglobin test | ++ | + | + | + | + |
| + | SNOMED-CT | +43396009 | +Hemoglobin A1c measurement | ++ | + | + | + | + |
| High Density Lipoprotein (HDL) | +LOINC | +14646-4 | +61 | +mg/dL | +>=40 mg/dL | +10-24-2010 10:00:00 | +Completed | +|
| + | CPT | +83701 | +Lipoprotein bld, hr fraction | ++ | + | + | + | + |
| + | SNOMED-CT | +28036006 | +High density lipoprotein cholesterol measurement | ++ | + | + | + | + |
| Low Density Lipoprotein (LDL) | +LOINC | +2089-1 | +106.6 | +mg/dL | +<130 mg/dL (calc) | +10-24-2010 10:00:00 | +Completed | +|
| + | CPT | +83721 | +Assay of blood lipoprotein | ++ | + | + | + | + |
| + | SNOMED-CT | +113079009 | +Low density lipoprotein cholesterol measurement | ++ | + | + | + | + |
| Total Cholesterol | +LOINC | +2093-3 | +197 | +mg/dL | +125-200 mg/dL | +10-24-2010 10:00:00 | +Completed | +|
| + | CPT | +82465 | +Assay, bld/serum cholesterol | ++ | + | + | + | + |
| + | SNOMED-CT | +121868005 | +Total cholesterol measurement | ++ | + | + | + | + |
| Triglycerides | +LOINC | +12951-0 | +147 | +mg/dL | +10-39 years: 55-110 mg/dL | 40-59 years: 70-150 mg/dL | >60 years: 80-150 mg/dL | Therapeutic Target: <100 mg/dL | +10-24-2010 10:00:00 | +Completed | +|
| + | CPT | +84478 | +Assay of triglycerides | ++ | + | + | + | + |
| + | SNOMED-CT | +14740000 | +Triglycerides measurement | ++ | + | + | + | + |
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ | Group Description | +Code System | +Code | +Code Description | +Date and Time | +Status | +
|---|---|---|---|---|---|
| Tobacco Use | +SNOMED-CT | +266919005 | +03-31-2010 10:00:00 | +Active | +|
| + | SNOMED-CT | +449868002 | +Current every day smoker | ++ | + |
+
+ Tobacco Use + Never smoker (Never Smoked)
+
+
+ | Group Description | +Code System | +Code | +Code Description | +Value | +Unit | +Date and Time | +Status | +
|---|---|---|---|---|---|---|---|
| BMI | +LOINC | +39156-5 | +31.3 | +kg/m2 | +03-31-2010 10:00:00 | +Finding | +|
| Diastolic Blood Pressure | +LOINC | +8462-4 | +92 | +mm[Hg] | +03-31-2010 10:00:00 | +Finding | +|
| Systolic Blood Pressure | +LOINC | +8480-6 | +145 | +mm[Hg] | +03-31-2010 10:00:00 | +Finding | +|
| BMI | +LOINC | +39156-5 | +30.7 | +kg/m2 | +05-23-2010 10:00:00 | +Finding | +|
| Diastolic Blood Pressure | +LOINC | +8462-4 | +100 | +mm[Hg] | +05-23-2010 10:00:00 | +Finding | +|
| Heart Rate | +LOINC | +8867-4 | +100 | +/min | +05-23-2010 10:00:00 | +Finding | +|
| Systolic Blood Pressure | +LOINC | +8480-6 | +160 | +mm[Hg] | +05-23-2010 10:00:00 | +Finding | +|
| Diastolic Blood Pressure | +LOINC | +8462-4 | +80 | +mm[Hg] | +05-28-2010 10:00:00 | +Finding | +|
| Heart Rate | +LOINC | +8867-4 | +88 | +/min | +05-28-2010 10:00:00 | +Finding | +|
| Systolic Blood Pressure | +LOINC | +8480-6 | +125 | +mm[Hg] | +05-28-2010 10:00:00 | +Finding | +|
| BMI | +LOINC | +39156-5 | +29.9 | +kg/m2 | +06-25-2010 10:00:00 | +Finding | +|
| Diastolic Blood Pressure | +LOINC | +8462-4 | +88 | +mm[Hg] | +06-25-2010 10:00:00 | +Finding | +|
| Heart Rate | +LOINC | +8867-4 | +86 | +/min | +06-25-2010 10:00:00 | +Finding | +|
| Systolic Blood Pressure | +LOINC | +8480-6 | +132 | +mm[Hg] | +06-25-2010 10:00:00 | +Finding | +|
| BMI | +LOINC | +39156-5 | +28.2 | +kg/m2 | +10-24-2010 10:00:00 | +Finding | +|
| Diastolic Blood Pressure | +LOINC | +8462-4 | +84 | +mm[Hg] | +10-24-2010 10:00:00 | +Finding | +|
| Heart Rate | +LOINC | +8867-4 | +84 | +/min | +10-24-2010 10:00:00 | +Finding | +|
| Systolic Blood Pressure | +LOINC | +8480-6 | +130 | +mm[Hg] | +10-24-2010 10:00:00 | +Finding | +
| Planned Activity | +Planned Date | +
|---|---|
| Colonoscopy | +20120512 | +
+
+
+
+ | Substance | +Reaction | +
|---|---|
| Penicillin | +Nausea | +
| Codeine | +Wheezing | +
| Medication | +Directions | +Start Date | +Status | +Indications | +Monitored by | +
|---|---|---|---|---|---|
| Proventil 0.09 MG/ACTUAT inhalant solution | +2 puffs q6 hours PRN wheezing | +Jan 3, 2013 | +Active | +Asthma | +Penny Puffer, MD | +
| Atenolol 25 MG Oral Tablet | +1 every 12 hours Orally | +Mar 18, 2013 | +Active | +Hypertension | ++ |
| Planned Care | +Start Date | +Patient Provider Rating | +Provider Provider Rating | +Provider | +Patient Support/Caregiver | +
|---|---|---|---|---|---|
| Encounter for Check-up | +October 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | +Dr. James Case | ++ |
| Care Goal: Weight loss from baseline weight 10% | +October 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | ++ | + |
| Nutrition Recommendation: Education | +July 31, 2013 | ++ | + | + | + |
+ | Result Type | +Result Value | +Relevant Reference Range | +Interpretation | +Date | +
|---|---|---|---|---|
| Hemoglobin | +13.2 g/dL | +Normal range for women is 12.0 to 15.5 grams per deciliter | +Normal | +July 31, 2013 | +
| Leukocytes | +6.7 10*9/L | +Normal white blood cell count range 3.5-10.5 billion cells/L | +Normal | +July 31, 2013 | +
| Platelets | +123 10*9/L | +Normal white blood cell count range 3.5-10.5 billion cells/L | +Low | +July 31, 2013 | +
| Hematocrit | +35.3 % | +Normal hematocrit range for female: 34.9-44.5 percent | +Normal | +July 31, 2013 | +
| Erythrocytes | +4.21 10*12/L | +Normal red blood cell count range 3.90-5.03 trillion cells/L | +Normal | +July 31, 2013 | +
| Urea nitrogen, Serum | +Pending | +Pending | +Pending | +July 31, 2013 | +
| Date / Time: | +Sept 10, 2012 | +Sept 1, 2011 | +
|---|---|---|
| Height | +177 cm | +177 cm | +
| Weight | +86 kg | +88 kg | +
| Blood Pressure | +132/88 | +128/80 | +
| Directive | +Description | +Verification | +Supporting Document(s) | +
|---|---|---|---|
| Resuscitation status | +
+ |
+ Dr. Patricia Primary, Feb 19, 2011 | +
+ |
+
| Substance | +Reaction | +
|---|---|
|
+ |
+
+ |
+
|
+ |
+
+ |
+
| Diagnosis | +Age At Onset | +
|---|---|
| Myocardial Infarction (cause of death) | +57 | +
| Diabetes | +40 | +
+
+ | Functional Category | +Effective Dates | +Results of Evaluation | +
|---|---|---|
| Functional Assessment | +March 11, 2013 | +Independent Walking | +
| ADL/IADL: Bathing | +March 11,2013 | +Independent | +
| Medication | +Directions | +Start Date | +Status | +Indications | +Monitored by | +
|---|---|---|---|---|---|
| Proventil 0.09 MG/ACTUAT inhalant solution | +2 puffs q6 hours PRN wheezing | +Jan 3, 2013 | +Active | +Asthma | +Penny Puffer, MD | +
| Atenolol 25 MG Oral Tablet | +1 every 12 hours Orally | +Mar 18, 2013 | +Active | +Hypertension | ++ |
+ Implants
+
+
+ Cardiac Pacemaker
+
+
+ Upper GI Prosthesis
+
+
+ Upper GI Prosthesis
+
+
+
+
+
+ | Mental Status Findings | +Effective Dates | +Condition Status | +
|---|---|---|
| Mental Function | +March 11, 2013 | +Impaired | +
| Mental Function | +March 11, 2013 | +Agressive Behavior | +
| Mental Function | +March 11, 2013 | +Difficulty understanding own emotions | +
| Mental Function | +March 11, 2013 | +Difficulty communicating Thoughts | +
+
+ Nutritional Status
+
+ | Planned Care | +Start Date | +Patient Provider Rating | +Provider Provider Rating | +Provider | +Patient Support/Caregiver | +
|---|---|---|---|---|---|
| Encounter for Check-up | +September 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | +Dr. James Case | ++ |
| Treatment: Wound Care | +September 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | ++ | Caregiver: Mother | +
| Nutrition Recommendation: Education | +September 15, 2013 | ++ | + | + | + |
| Immunization: Influenza virus vaccine, IM | +November 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | +Dr. Henry Seven | ++ |
+
+ Influenza virus vaccine
+
+ | Procedure | +Date | +
|---|---|
|
+ |
+ 1998 | +
+
+
+
+
+
+
+
+
+
+
+
+
+ | Result Type | +Result Value | +Relevant Reference Range | +Interpretation | +Date | +
|---|---|---|---|---|
|
+ |
+
+ |
+
+ |
+ Normal | +March 11, 2013 | +
|
+ |
+
+ |
+
+ |
+ Normal | +March 11, 2013 | +
|
+ |
+
+ |
+
+ |
+ Low | +March 11, 2013 | +
|
+ |
+
+ |
+
+ |
+ Normal | +March 11, 2013 | +
|
+ |
+
+ |
+
+ |
+ Normal | +March 11, 2013 | +
|
+ |
+ Pending | +Pending | +Pending | +March 11, 2013 | +
| Date / Time: | +Sept 10, 2012 | +Sept 1, 2011 | +
|---|---|---|
| Height | +
+ |
+
+ |
+
| Weight | +
+ |
+
+ |
+
| Blood Pressure | +
+ |
+
+ |
+
| Substance | +Reaction | +
|---|---|
|
+ |
+
+ |
+
|
+ |
+
+ |
+
| Directive | +Description | +Verification | +Supporting Document(s) | +
|---|---|---|---|
| Resuscitation status | +
+ |
+ Dr. Patricia Primary, Feb 19, 2011 | +
+ |
+
| Encounter | +Performer | +Location | +Date | +
|---|---|---|---|
|
+ |
+ Amanda Assigned, General Physician | +Good Health Clinic | +February 12, 2013 | +
+ Checkup Examination
+
+ | Diagnosis | +Age At Onset | +
|---|---|
| Myocardial Infarction (cause of death) | +57 | +
| Diabetes | +40 | +
+
+ | Functional Category | +Effective Dates | +Results of Evaluation | +
|---|---|---|
| Functional Assessment | +March 11, 2013 | +Independent Walking | +
| ADL/IADL: Bathing | +March 11,2013 | +Independent | +
| Vaccine | +Date | +Status | +Series number | +
|---|---|---|---|
|
+ |
+ Nov 1999 | +Completed | +N/A | +
|
+ |
+ Dec 1998 | +Completed | +N/A | +
|
+ |
+ Dec 1998 | +Completed | +N/A | +
|
+ |
+ 1997 | +Refused | +N/A | +
| Hepatitis B | +Aug 1, 2012 | +Completed | +3rd | +
+ Influenza, seasonal, IM
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Implants
+
+
+ Cardiac Pacemaker
+
+
+ Upper GI Prosthesis
+
+
+ Upper GI Prosthesis
+
+
+
+
+
+ | Mental Status Findings | +Effective Dates | +Condition Status | +
|---|---|---|
| Mental Function | +March 11, 2013 | +Impaired | +
| Mental Function | +March 11, 2013 | +Agressive Behavior | +
| Mental Function | +March 11, 2013 | +Difficulty understanding own emotions | +
| Mental Function | +March 11, 2013 | +Difficulty communicating Thoughts | +
+ Nutritional Status
+
+ | Current Medication | +Directions | +Start Date | +Status | +Indications | +Monitored by | +
|---|---|---|---|---|---|
| Proventil 0.09 MG/ACTUAT inhalant solution | +2 puffs q6 hours PRN wheezing | +Jan 3, 2013 | +Active | +Asthma | +Penny Puffer, MD | +
| Atenolol 25 MG Oral Tablet | +1 every 12 hours Orally | +Mar 18, 2013 | +Active | +Hypertension | ++ |
| Payer name | +Policy type / Coverage type | +Policy ID | +Covered party ID | +Policy Holder | +
|---|---|---|---|---|
| Good Health Insurance | +Extended healthcare / Family | +Contract Number | +1138345 | +Patient's Mother | +
| Planned Care | +Start Date | +Patient Provider Rating | +Provider Provider Rating | +Provider | +Patient Support/Caregiver | +
|---|---|---|---|---|---|
| Encounter for Check-up | +June 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | +Dr. James Case | ++ |
| Care Goal: Pulse Oximetry 95% | +June 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | ++ | Caregiver: Mother | +
| Treatment: Wound Care | +June 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | ++ | Caregiver: Mother | +
| Nutrition Recommendation: Education | +June 13, 2013 | ++ | + | + | + |
| Procedure: Colonoscopy | +June 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | ++ | Caregiver: Mother | +
| Medication: Heparin 0.25 ml pre-filled syringe | +July 12, 2013 | +1st, Normal Priority | +3rd, Normal Priority | ++ | Caregiver: Mother | +
| Supply: 0.25 ML Heparin sodium 10000 UNT/ML Prefilled Syringe | +June 15, 2013 | ++ | + | Dr. Henry Seven | ++ |
| Immunization: Influenza virus vaccine, IM | +November 15, 2013 | +1st, Normal Priority | +3rd, Normal Priority | +Dr. Henry Seven | ++ |
+
+ Influenza virus vaccine
+
+
+
+ | Procedure | +Date | +
|---|---|
|
+ |
+ 1998 | +
+
+
+
+
+
+
+
+
+
+
+
+
+ | Result Type | +Result Value | +Relevant Reference Range | +Interpretation | +Date | +
|---|---|---|---|---|
|
+ |
+
+ |
+
+ |
+ Normal | +March 11, 2013 | +
|
+ |
+
+ |
+
+ |
+ Normal | +March 11, 2013 | +
|
+ |
+
+ |
+
+ |
+ Low | +March 11, 2013 | +
|
+ |
+
+ |
+
+ |
+ Normal | +March 11, 2013 | +
|
+ |
+
+ |
+
+ |
+ Normal | +March 11, 2013 | +
|
+ |
+ Pending | +Pending | +Pending | +March 11, 2013 | +
| Social History Element | +Description | +Effective Dates | +
|---|---|---|
| Alcohol Use | +2 Drinks per Week | +March 12, 2013 | +
| Smoking Status | +Former smoker | +May 1, 2005 - Feb 27, 2009 | +
| Characteristics of Home Environment | +Unsatisfactory Living Conditions | +March 12, 2013 | +
| Cultural and Religious Observations | +Does not accept blood transfusions, or donates, or stores blood for transfusion. | +March 12, 2013 | +
| Date / Time: | +February 12, 2013 | +August 1, 2013 | +
|---|---|---|
| Height | +
+ |
+
+ |
+
| Weight | +
+ |
+
+ |
+
| Blood Pressure | +
+ |
+
+ |
+