# 170.315_b1_toc_inp_ccd_r21_sample1 test data

Patient | Lindsey Pitt
Date of birth | June 1, 1970
Sex | Female
Race | White
Ethnicity | Not Hispanic or Latino
Contact info | Primary Home: 1006 Amber Dr Beaverton, OR 97266, US Tel: +1(555)-223-1234
Patient IDs | 117273338 2.16.840.1.113883.4.1

Document Id | TT106 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 Ralph Issac
Contact info | Primary Home: 1006 Amber Dr Beaverton, OR 97266, US Tel: +1(555)-224-1544
Personal relationship | Mr Franklin Pitt
Contact info | Primary Home: 1006 Amber Dr Beaverton, OR 97266, US Tel: +1(555)-224-1544

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 | Franklin Pitt

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

- Security and Privacy Prohibitions
- ALLERGIES AND ADVERSE REACTIONS
- MEDICATIONS
- Discharge Medications
- PROBLEMS
- ENCOUNTERS
- ADMISSION DIAGNOSIS
- PROCEDURES
- Implants
- IMMUNIZATIONS
- VITAL SIGNS
- SOCIAL HISTORY
- RESULTS
- FUNCTIONAL STATUS
- MENTAL STATUS
- ASSESSMENTS
- TREATMENT PLAN
- Goals Section
- Health Concerns Section
- HOSPITAL DISCHARGE INSTRUCTIONS

### Security and Privacy Prohibitions

Section Author: Dr. Davis Albert, Neighborhood Physicians Practice
PROHIBITION ON REDISCLOSURE OF CONFIDENTIAL INFORMATION
This notice accompanies a disclosure of information concerning a client in alcohol/drug treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

### 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 200mg | Two Times Daily | June 22, 2015
Tylenol 500mg | As needed | June 22, 2015
Darbepoetin Alfa 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 1mg | Daily | June 23, 2015
Prednisolone 50mg | 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 250mg | Three times daily | June 25, 2015

### Discharge Medications

No Information

### PROBLEMS

Active Concerns

- Problem #1
  - Essential hypertension (Disorder)
- Problem #2
  - Severe Hypothyroidism (Disorder)
- Problem #3
  - Chronic rejection of renal transplant (disorder)
- Problem #4
  - Iron deficiency anemia (disorder))
- Problem #5
  - Interstitial pneumonia (disorder)

Resolved Concerns

- Problem #6
  - Overweight (finding)

### ENCOUNTERS

Encounter Diagnosis | Location | Date
--- | --- | ---
Anemia in Chronic Kidney Disease | Community Health and Hospitals | June 22, 2015 at 10:00am 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
--- | --- | ---
Influenza Virus Vaccine | May 10, 2014 | Completed
Tetanus and diphtheria toxoids | January 4, 2012 | Completed
influenza, intradermal, quadrivalent, preservative free | June 22, 2015 | Refused

### 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 | 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.