# 170.315_b1_toc_inp_ds_r21_sample2 test data

Patient | William Dossier, jr
Date of birth | May 1, 1980
Sex | Male
Race |
Ethnicity |
Contact info | Primary Home: 1008 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-227-1234
Patient IDs | 119293340 2.16.840.1.113883.4.1

Document Id | TT108 2.16.840.1.113883.19.5.99999.1
Document Created: | July 22, 2015, 18:00:00, EST

Care provision | Burn by Fire from July 22, 2015, 18:00:00, EST to July 22, 2015, 23:00:00 -5000
Performer (primary care physician) | Dr Henry Seven of Community Health and Hospitals
Performer | Mary McDonald

Author | Dr Henry Seven
Contact info | 1002 Healthcare Dr Portland, OR 97266, US Tel: +1(555)-555-1002

Encounter Id | 9937012 2.16.840.1.113883.19
Encounter Date | From July 22, 2015, 18:00:00, EST to July 22, 2015, 23:00:00 -5000

Personal relationship | Mr. Graham Dossier
Contact info | Primary Home: 1008 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-228-1544
Personal relationship | Ms Racheal Dossier
Contact info | Primary Home: 1008 Amber Dr Beaverton, OR 97006, US Tel: +1(555)-228-1544

Entered by | Mary McDonald
Contact info | 1002 Healthcare Dr Portland, OR 97266, US Tel: +1(555)-555-1002

Signed | Dr Henry Seven at July 22, 2015
Contact info | 1002 Healthcare Dr Portland, OR 97266, US Tel: +1(555)-555-1002

Informant | Henry Seven
Contact info | 1002 Healthcare Dr Portland, OR 97266, US Tel: +1(555)-555-1002
Informant | Racheal Dossier

Information recipient: | Dr Henry Seven

Legal authenticator | Dr Henry Seven signed at July 22, 2015
Contact info | 1002 Healthcare Dr Portland, OR 97266, US Tel: +1(555)-555-1002

Document maintained by | Community Health and Hospitals
Contact info | 1002 Healthcare Dr Portland, OR 97266, US Tel: +1(555)-555-5000

## Table of Contents

- ALLERGIES AND ADVERSE REACTIONS
- MEDICATIONS
- Admission Medications
- Discharge Medications
- PROBLEMS
- ENCOUNTERS
- ADMISSION DIAGNOSIS
- PROCEDURES
- MEDICAL EQUIPMENT
- IMMUNIZATIONS
- VITAL SIGNS
- SOCIAL HISTORY
- RESULTS
- ASSESSMENTS
- TREATMENT PLAN
- Goals Section
- Health Concerns
- HOSPITAL DISCHARGE INSTRUCTIONS
- MENTAL STATUS
- FUNCTIONAL STATUS
- HOSPITAL COURSE
- Discharge Diagnosis

### ALLERGIES AND ADVERSE REACTIONS

No Known Allergies

### MEDICATIONS

No known Medications

### Admission Medications

No Medications Administered

### Discharge Medications

No Information

### PROBLEMS

No known health problems

### ENCOUNTERS

No Encounters

### ADMISSION DIAGNOSIS

Skin burn

### PROCEDURES

Procedure | Date
--- | ---
Application of Dressing for burn | July 22, 2015

### MEDICAL EQUIPMENT

Patient has no history of implantable devices

### IMMUNIZATIONS

No immunization history

### VITAL SIGNS

Date / Time: | June 22, 2015
--- | ---
Height | 177 cm
Weight | 88 kg
Blood Pressure | 145/88

Date / Time: | July 22, 2015
--- | ---
Body Temperature | 99 degrees Fahrenheit

### SOCIAL HISTORY

Social History Observation | Description | Dates Observed
--- | --- | ---
Current Smoking Status | Current every day | July 22, 2015
Birth Sex | Male | July 22, 2015

### RESULTS

Laboratory Test: None needed. Laboratory Values/Results: No Lab Result data

### ASSESSMENTS

The patient Mr William Dossier was found to have first degree burns and Dr Seven and his staff Mr Dossier by cleaning the burn and dressing the burn and observed for couple of hours before discharging Mr Dossier.

### TREATMENT PLAN

Hand-off Communication:

Planned Care | Start Date
--- | ---
Schedule an appointment with Dr Seven after 1 week for Follow up with Outpatient facility. | July 29, 2015
Medication: Tylenol 500mg | As needed

### Goals Section

No goal information

### Health Concerns

No Known Health Concerns on 07/22/2015

### HOSPITAL DISCHARGE INSTRUCTIONS

1. Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility.
2. In case of fever, take Tylenol as advised in plan of treatment.

### MENTAL STATUS

No Mental Status information

### FUNCTIONAL STATUS

No Functional Status information

### HOSPITAL COURSE

Mr. William Dossier is a 35 year old male who is healthy and visits Community Health Hospitals on 7/22/2015 6pm EST due to a skin burn. The doctor examines the burn, applies the needed dressing and discharges the person after a few hours.

### Discharge Diagnosis

The doctor examines the burn, applies the needed dressing and discharges the person after a few hours.