# Community Health and Hospitals: Health Summary

Patient | Myra 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: | September 12, 2012, 00:00:00 -0000

Care provision | Pnuemonia from August 6, 2012 to August 13, 2012
Performer (primary care provider) | Dr. Henry Seven of Community Health and Hospitals
Performer (primary care provider) | Dr. Henry Seven of Community Health and Hospitals

Author | Dr 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 to August 13, 2012
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 13, 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 13, 2012
Contact info | 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002

Document maintained by | Community Health and Hospitals
Contact info | Work Place: 1002 Healthcare Drive Portland, OR 97266, US Tel: 555-555-1002

## Table of Contents

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

### ALLERGIES, ADVERSE REACTIONS, ALERTS

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

### ENCOUNTERS

Encounter | Performer | Location | Date
--- | --- | --- | ---
Pnuemonia | Dr Henry Seven | Community Health and Hospitals | 20120806

### FAMILY HISTORY

Father (deceased)

Diagnosis | Age At Onset
--- | ---
Myocardial Infarction (cause of death) | 57
Diabetes | 40

### 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
--- | ---
Consultation with Dr George Potomac for Asthma | 20120820
Chest X-ray | 20120826
Sputum Culture | 20120820

### HOSPITAL DISCHARGE MEDICATIONS

Medication | Directions | Start Date | Status | Indications | Fill Instructions
--- | --- | --- | --- | --- | ---
120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler | 0.11 MG/ACTUAT Metered Dose Once Daily | 20120813 | Active | Bronchitis (32398004 SNOMED CT) | Generic Substitition Allowed

### REASON FOR REFERRAL

Follow up with Dr George Potomac for Asthma

### PROBLEMS

1. Pneumonia : Status - Resolved

### PROCEDURES

Procedure | Date
--- | ---
Chest X-Ray | 8/7/2012

### 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]

### HOSPITAL DISCHARGE INSTRUCTIONS

Ms. Jones, you have been seen by Dr. Henry Seven at Local Community Hospital from August 8th until August 13th 2012. You are currently being discharged from Local Community Hospital. Dr. Seven has provided the following instructions to you at this time; should you have any questions please contact a member of your healthcare team prior to discharge. If you have left the hospital and have questions, please contact Dr. Seven at 555-555-1002. Instructions:

1. Take all medications as prescribed.
2. Please monitor your peak flows. If your peak flows drop to 50% of normal, call my office immediately or return to the Emergency Room.
3. If you experience any of the following symptoms, call my office immediately or return to the Emergency Room:
   1. Shortness of Breath
   2. Dizziness or Light-headedness
   3. Fever, chills, or diffuse body aches
   4. Pain or redness at the site of any previous intravenous catheter
   5. Any other unusual problem