# Get Well Clinic: Health Summary

Patient | Isabella Jones
Date of birth | May 1, 1947
Sex | Female
Race | White
Ethnicity | Not Hispanic or Latino
Contact info | Primary Home: 1357 Amber Drive Beaverton, OR 97006, US Tel: (816)276-6909
Patient IDs | 1 2.16.840.1.113883.4.6 123-101-5230 2.16.840.1.113883.4.1

Document Id | Test CCDA 1.1.1.1.1.1.1.1.1
Document Created: | August 6, 2012

Care provision | Pnuemonia from August 6, 2012, 00:28 +0500 to August 6, 2012, 00:58 +0500
Performer (primary care provider) | Dr. Henry Seven of Get Well Clinic

Author | Henry Seven
Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002

Encounter Id | 1 2.16.840.1.113883.4.6
Encounter Type | Pnuemonia
Encounter Date | From August 6, 2012, 00:28 +0500 to August 6, 2012, 00:58 +0500
Encounter Location | id: 2.16.840.1.113883.4.6
Responsible party | Dr Henry Seven

Personal relationship | Mr. Ralph Jones
Contact info | Primary Home: 1357 Amber Drive Beaverton, OR 97006, US Tel: (555)555-2006
Personal relationship | Mr. Frank Jones
Contact info | Primary Home: 1357 Amber Drive Beaverton, OR 97006, US Tel: (555)555-2006

Entered by | Mary McDonald
Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002

Signed | Henry Seven at August 6, 2012
Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002

Informant | Henry Seven
Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002
Informant | Frank Jones

Information recipient: | Henry Seven

Legal authenticator | Henry Seven signed at August 6, 2012
Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002

Document maintained by | Get Well Clinic
Contact info | Work Place: 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002

## Table of Contents

- ALLERGIES, ADVERSE REACTIONS, ALERTS
- ENCOUNTERS
- IMMUNIZATIONS
- Medications
- CARE PLAN
- REASON FOR REFERRAL
- PROBLEMS
- PROCEDURES
- FUNCTIONAL STATUS
- RESULTS
- SOCIAL HISTORY
- VITAL SIGNS

### ALLERGIES, ADVERSE REACTIONS, ALERTS

Substance | Reaction | Severity | Status
--- | --- | --- | ---
Codeine | Shortness of Breath | Moderate | Active

### ENCOUNTERS

Encounter | Performer | Location | Date
--- | --- | --- | ---
Pnuemonia | Dr Henry Seven | Get Well Clinic | 20120806

### IMMUNIZATIONS

Vaccine | Date | Status
--- | --- | ---
Influenza virus vaccine | May 2012 | Completed
Tetanus and diphtheria toxoids | April 2012 | Completed

### Medications

Medication | Directions | Start Date | Status | Indications | Fill Instructions
--- | --- | --- | --- | --- | ---
Albuterol 0.09 MG/ACTUAT inhalant powder | Albuterol 0.09 MG/ACTUAT inhalant powder, 2 puffs | 20120806 | Active | Pneumonia (233604007 SNOMED CT) | Generic Substitition Allowed

### CARE PLAN

Planned Activity | Planned Date
--- | ---
Admit Yourself to Community Health and Hospitals for Pnuemonia | 20120806

### REASON FOR REFERRAL

Recommend Admission to Community Health and Hospitals for Pnuemonia

### PROBLEMS

1. Pneumonia : Status - Active

### PROCEDURES

Procedure | Date
--- | ---
Chest X-Ray | 2012

### FUNCTIONAL STATUS

Functional Condition | Effective Dates | Condition Status
--- | --- | ---
Dependence on cane | November 1, 2008 | Active
Memory impairment | November 1, 2008 | Active

### RESULTS

Result Type | Result Value
--- | ---
HGB | 10.2 g/dL
WBC | 12.3 10*3/uL
PLT | 123 10*3/uL

### SOCIAL HISTORY

Social History Element | Description | Effective Dates
--- | --- | ---
smoking | Former Smoker (1 pack per day | 20050501 to 20110227

### VITAL SIGNS

Date / Time: | Nov 1, 2011 | August 6, 2012
--- | --- | ---
Height | 175 cm | 175 cm
Weight | 88 kg | 90 kg
Blood Pressure | 132/86 mm[Hg] | 145/88 mm[Hg]