# 170.315_b1_toc_amb_ccd_r21_sample1 test data

Patient | Myra Banks
Date of birth | June 1, 1970
Sex | Female
Race | White
Ethnicity | Not Hispanic or Latino
Contact info | Primary Home: 1003 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-115-1234
Patient IDs | 113243335 2.16.840.1.113883.4.1

Document Id | TT103 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 | Amb EMR v1.0
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 Christopher Jones
Contact info | Primary Home: 1003 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-116-1544
Personal relationship | Mr Glazer Banks
Contact info | Primary Home: 1003 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-116-1544

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 | Glazer Banks

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

## Table of Contents

- ALLERGIES AND ADVERSE REACTIONS
- MEDICATIONS
- PROBLEMS
- ENCOUNTERS
- IMMUNIZATIONS
- VITAL SIGNS
- SOCIAL HISTORY
- PROCEDURES
- Implants
- 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 | Hives | Moderate | Active
Ampicillin | Hives | Moderate | Active

### MEDICATIONS

Medication | Directions | Start Date
--- | --- | ---
Ceftriaxone 100 MG/ML | Two Times Daily | June 22, 2015
Tylenol 500mg | As needed for 10 days | June 22, 2015
Darbepoetin 0.5 MG/ML | Once a week | June 22, 2015

### PROBLEMS

Active Concerns

- Problem #1
  - Essential hypertension (Disorder)
- Problem #2
  - Severe Hypothyroidism (Disorder)
- Problem #3
  - Chronic rejection of renal transplant (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 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 smoker | June 22, 2015
Birth Sex | Female | June 22, 2015

### PROCEDURES

Procedure | Date
--- | ---
Nebulizer Therapy | 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

### 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 | 50 mg/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 | 100 mg/dL | negative |  | 06/22/2015

### FUNCTIONAL STATUS

Functional Category | Effective Dates
--- | ---
Dependence on Cane | May 01, 2005

### ASSESSMENTS

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 29, 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 22, 2015
Need to gain more energy to do regular activities (Visual Inspection) | N/A | June 22, 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 Myra Banks 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