Header
Composition/9a4bd04c-2e29-9fc6-12bd-f3dd3a4853ec
{
"date" : "2015-06-22",
"encounter" : {
"reference" : "urn:uuid:690487e1-3b05-37ea-c11f-fb3e15491628"
},
"section" : [ {
"title" : "ALLERGIES AND ADVERSE REACTIONS",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Substance</th>\n <th>Reaction</th>\n <th>Severity</th>\n <th>Status</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>\n <content ID=\"product1\">Penicillin G</content>\n </td>\n <td>\n <content ID=\"reaction1\">Hives</content>\n </td>\n <td>\n <content ID=\"severity1\">Moderate</content>\n </td>\n <td>Active</td>\n </tr>\n <tr>\n <td>\n <content ID=\"product2\">Ampicillin</content>\n </td>\n <td>\n <content ID=\"reaction2\">Hives</content>\n </td>\n <td>\n <content ID=\"severity2\">Moderate</content>\n </td>\n <td>Active</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:aea7c259-3c0d-c306-06a0-5b3105360530"
}, {
"reference" : "urn:uuid:7c2e42e1-d5f4-e347-937c-ac2823ac5e0c"
} ],
"code" : {
"coding" : [ {
"code" : "48765-2",
"display" : "48765-2",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "MEDICATIONS",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Medication</th>\n <th>Directions</th>\n <th>Start Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Ceftriaxone 100MG/ML</td>\n <td>Two times daily</td>\n <td>June 22, 2015</td>\n </tr>\n <tr>\n <td>Vantin 200mg</td>\n <td>Two Times daily</td>\n <td>June 22, 2015</td>\n </tr>\n <tr>\n <td>Tylenol 500mg</td>\n <td>As needed</td>\n <td>June 22, 2015</td>\n </tr>\n <tr>\n <td>Darbepoetin 0.5 MG/ML</td>\n <td>Once a week</td>\n <td>June 22, 2015</td>\n </tr>\n <tr>\n <td>Clindamycin 300mg</td>\n <td>Three times daily</td>\n <td>June 23, 2015</td>\n </tr>\n <tr>\n <td>Torsemide 20mg</td>\n <td>Daily</td>\n <td>June 23, 2015</td>\n </tr>\n <tr>\n <td>Levothyroxine Sodium 1mg</td>\n <td>Daily</td>\n <td>June 23, 2015</td>\n </tr>\n <tr>\n <td>Prednisolone 50mg</td>\n <td>Daily</td>\n <td>June 23, 2015</td>\n </tr>\n <tr>\n <td>FenoFibric Acid 35mg</td>\n <td>At the Hour of Sleep</td>\n <td>June 24, 2015</td>\n </tr>\n <tr>\n <td>Mycophenolic Acid 360mg</td>\n <td>Two times daily</td>\n <td>June 24, 2015</td>\n </tr>\n <tr>\n <td>Everolimus 0.5mg</td>\n <td>Two times daily</td>\n <td>June 24, 2015</td>\n </tr>\n <tr>\n <td>Ciprofloxacin 250mg</td>\n <td>Three times daily</td>\n <td>June 25, 2015</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:21e15fd2-89a6-6712-e643-3194fdf6b22d"
}, {
"reference" : "urn:uuid:8d7bc244-fd07-aa97-f27c-7755882a974c"
}, {
"reference" : "urn:uuid:27c6a57b-5884-4199-918c-65a3fe4888cf"
}, {
"reference" : "urn:uuid:0a45ced4-b8e9-9a0a-f06c-ffc0fe9ab4d5"
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"reference" : "urn:uuid:ff39a8ad-856a-d366-34ad-0d94232d3454"
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"reference" : "urn:uuid:c464da22-c06c-3d98-1f4a-a24c46ea6a8a"
}, {
"reference" : "urn:uuid:39da8f60-3579-1b4b-18a5-bef7aac573df"
}, {
"reference" : "urn:uuid:c2f18848-d0bd-aa1a-17b7-ace451db08ca"
}, {
"reference" : "urn:uuid:fcab2249-a577-e1ac-1339-0312acb7ed2e"
}, {
"reference" : "urn:uuid:8625ef94-1a5c-35fa-94b0-9bf1d6bb2033"
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}, {
"reference" : "urn:uuid:e2c3c20b-ec8a-dfaf-240a-50716d940d8e"
} ],
"code" : {
"text" : "HISTORY OF MEDICATION USE",
"coding" : [ {
"code" : "10160-0",
"display" : "HISTORY OF MEDICATION USE",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Discharge Medications",
"text" : {
"div" : "No Information",
"status" : "generated"
},
"code" : {
"text" : "Hospital Discharge Medications",
"coding" : [ {
"code" : "10183-2",
"display" : "Hospital Discharge Medications",
"system" : "http://loinc.org"
}, {
"code" : "75311-1",
"display" : "Discharge Medications",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "PROBLEMS",
"text" : {
"div" : "\n <paragraph>Active Concerns</paragraph>\n <list>\n <item>Problem #1\n\t\t\t\t\t\t\t\t\n <list>\n <item>Essential hypertension (Disorder)</item>\n </list>\n </item>\n <item>Problem #2\n\t\t\t\t\t\t\t\t\n <list>\n <item>Severe Hypothyroidism (Disorder)</item>\n </list>\n </item>\n <item>Problem #3\n\t\t\t\t\t\t\t\t\n <list>\n <item>Chronic rejection of renal transplant (disorder)</item>\n </list>\n </item>\n <!-- newly added -db -->\n <item>Problem #4\n\t\t\t\t\t\t\t\t\n <list>\n <item>Iron deficiency anemia (disorder))</item>\n </list>\n </item>\n <!-- replaces fever -db -->\n <item>Problem #5\n\t\t\t\t\t\t\t\t\n <list>\n <item>Interstitial pneumonia (disorder)</item>\n </list>\n </item>\n </list>\n <paragraph>Resolved Concerns</paragraph>\n <list>\n <item>Problem #6\n\t\t\t\t\t\t\t\t\n <list>\n <item>Overweight (finding)</item>\n </list>\n </item>\n </list>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:33db8cd1-6791-0b52-3385-b44d9808a65c"
}, {
"reference" : "urn:uuid:d657f517-b17e-36e7-2578-78e218a8f326"
}, {
"reference" : "urn:uuid:a3e5ed2e-b8cb-387a-5aad-b0fe995e8c8c"
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"reference" : "urn:uuid:ea2d538e-acde-d226-c2a5-c520ea552233"
}, {
"reference" : "urn:uuid:174781a0-6e20-b522-c93e-8e95558830e0"
}, {
"reference" : "urn:uuid:ab064999-98c5-3a60-efa1-50167c2e1859"
} ],
"code" : {
"text" : "PROBLEM LIST",
"coding" : [ {
"code" : "11450-4",
"display" : "PROBLEM LIST",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "ENCOUNTERS",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Encounter Diagnosis</th>\n <th>Location</th>\n <th>Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td ID=\"Encounter1\"> Anemia in Chronic Kidney Disease</td>\n <td>Community Health and Hospitals</td>\n <td>June 22, 2015 at 8:00am</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:0824b62d-cd1e-23c3-e1ed-e145b5a20485"
} ],
"code" : {
"text" : "History of encounters",
"coding" : [ {
"code" : "46240-8",
"display" : "History of encounters",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "ADMISSION DIAGNOSIS",
"text" : {
"div" : "Anemia",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:058d4bad-4582-6aa5-d2fa-ed432c4f4663"
} ],
"code" : {
"text" : "Hospital Admission Diagnosis",
"coding" : [ {
"code" : "46241-6",
"display" : "Hospital Admission Diagnosis",
"system" : "http://loinc.org"
}, {
"code" : "42347-5",
"display" : "Admission Diagnosis",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "PROCEDURES",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Procedure</th>\n <th>Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td ID=\"Proc1\">Bronchoscopy</td>\n <td>June 22, 2015</td>\n </tr>\n <tr>\n <td ID=\"Proc2\">Chest X-Ray, PA and Lateral Views</td>\n <td>June 22, 2015</td>\n </tr>\n <tr>\n <td ID=\"Proc3\">Introduction of cardiac pacemaker system via vein</td>\n <td>October 5, 2011</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:f412971f-2b96-bf84-7f17-0db06a32993e"
}, {
"reference" : "urn:uuid:f6403b17-93a9-dd65-5e80-532c3f96177d"
}, {
"reference" : "urn:uuid:b3cd6708-6dfd-0ddd-1aa0-a6d03781a2cc"
} ],
"code" : {
"text" : "HISTORY OF PROCEDURES",
"coding" : [ {
"code" : "47519-4",
"display" : "HISTORY OF PROCEDURES",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Implants",
"text" : {
"div" : "\n <table>\n <thead>\n <tr>\n <th>Implanted</th>\n <th>Area</th>\n <th>UDI</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td ID=\"implant1\">Cardiac Pacemaker</td>\n <td>Subclavian Vein</td>\n <td>(01)00643169007222(17)160128(21)BLC200461H</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:fe24fc80-7415-f6da-686e-93b7daabc4fc"
} ],
"code" : {
"text" : "Medical Equipment",
"coding" : [ {
"code" : "46264-8",
"display" : "Medical Equipment",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "IMMUNIZATIONS",
"text" : {
"div" : "\n <content ID=\"immunSect\"/>\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Vaccine</th>\n <th>Date</th>\n <th>Status</th>\n <th>Series number</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>\n <content ID=\"immun1\"/>Influenza Virus Vaccine\n </td>\n <td>May 10, 2014</td>\n <td>Completed</td>\n <td>N/A</td>\n </tr>\n <tr>\n <td>\n <content ID=\"immun2\"/>Tetanus and diphtheria toxoids\n </td>\n <td>January 4, 2012</td>\n <td>Completed</td>\n <td>N/A</td>\n </tr>\n <tr>\n <td>\n <content ID=\"immun3\"/>influenza, intradermal, quadrivalent, preservative free\n </td>\n <td>June 22, 2015</td>\n <td>Refused</td>\n <td>N/A</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:b9a0ac12-01b4-8229-6b27-43f9ce6fad8d"
}, {
"reference" : "urn:uuid:96193893-d945-c9b9-374f-41fe52657427"
}, {
"reference" : "urn:uuid:a0aa6527-7778-5454-6c2a-d63966273566"
} ],
"code" : {
"text" : "History of immunizations",
"coding" : [ {
"code" : "11369-6",
"display" : "History of immunizations",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "VITAL SIGNS",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th align=\"right\">Date / Time: </th>\n <th>June 22, 2015</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <th align=\"left\">Height</th>\n <td ID=\"vit1\">177 cm</td>\n </tr>\n <tr>\n <th align=\"left\">Weight</th>\n <td ID=\"vit2\">88 kg</td>\n </tr>\n <tr>\n <th align=\"left\">Blood Pressure</th>\n <td ID=\"vit3\">145/88 mm[Hg]</td>\n </tr>\n <tr>\n <th align=\"left\">Heart Rate</th>\n <td ID=\"vit4\">80 beats per minute</td>\n </tr>\n <tr>\n <th align=\"left\">O2 Percentage BldC Oximetry</th>\n <td ID=\"vit5\">95 percent</td>\n </tr>\n <tr>\n <th align=\"left\">Body Temperature</th>\n <td ID=\"vit6\">38 degree celsius</td>\n </tr>\n <tr>\n <th align=\"left\">Respiratory Rate</th>\n <td ID=\"vit7\">18 breaths per minute</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:23682a90-3662-4333-7ffe-95a1660f6548"
}, {
"reference" : "urn:uuid:8b00851a-d9d6-6eea-e9d1-c98fdccc0033"
}, {
"reference" : "urn:uuid:5cce058a-40f3-35d2-cf3b-93b9d086038f"
}, {
"reference" : "urn:uuid:4d0cbdb9-c30c-96bd-3303-520c54b71c18"
}, {
"reference" : "urn:uuid:94c11d14-3a96-3f7c-4f6a-79f64d29aeab"
}, {
"reference" : "urn:uuid:41c337df-fa54-e314-eacd-8868ffaa194f"
}, {
"reference" : "urn:uuid:cceab64a-1799-fa35-3187-d9b6f5453b2c"
}, {
"reference" : "urn:uuid:350a0b35-a993-5195-8f0e-4484f26819f9"
} ],
"code" : {
"text" : "VITAL SIGNS",
"coding" : [ {
"code" : "8716-3",
"display" : "VITAL SIGNS",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "SOCIAL HISTORY",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Social History Observation</th>\n <th>Description</th>\n <th>Dates Observed</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Smoking Status</td>\n <td>Heavy tobacco smoker, ??-??/day</td>\n <td>May 1, 2005 - February 27, 2011</td>\n </tr>\n <tr>\n <td>Current Smoking Status</td>\n <td>Current every day</td>\n <td>June 22, 2015</td>\n </tr>\n <tr>\n <td ID=\"BirthSexInfo\">Birth Sex</td>\n <td>Female</td>\n <td>June 22, 2015</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:b1cb6a5e-a191-df52-b6a6-b605d9239e1b"
}, {
"reference" : "urn:uuid:499d0c99-d168-acd2-2066-16a1ea7c1c19"
}, {
"reference" : "urn:uuid:b27b4f7f-b425-25a1-d1a7-46c82381017d"
}, {
"reference" : "urn:uuid:581f645e-94ba-9c37-88e0-75d1eeada3ab"
}, {
"reference" : "urn:uuid:84f95ace-85c9-07fd-cfdb-f348d2e908fd"
} ],
"code" : {
"text" : "Social History",
"coding" : [ {
"code" : "29762-2",
"display" : "Social History",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "RESULTS",
"text" : {
"div" : "\n <table>\n <thead>\n <tr>\n <th>Result Type</th>\n <th>Result Value</th>\n <th>Relevant Reference Range</th>\n <th>Interpretation</th>\n <th>Date</th>\n </tr>\n </thead>\n <tbody>\n <!-- next 5 are inpatient specific -->\n <!-- this 1st item is from Laboratory Tests' and has no result yet as it is just a test -db -->\n <!-- inp (only) test -->\n <!-- inp (only) results -->\n <tr>\n <td ID=\"resultB\">HGB</td>\n <td ID=\"resultvalueB\">10.2 g/dL</td>\n <td ID=\"referencerangeB\"></td>\n <td></td>\n <td>06/22/2015</td>\n </tr>\n <tr>\n <td ID=\"resultC\">WBC</td>\n <td ID=\"resultvalueC\">12.3 (10*3/uL)</td>\n <td ID=\"referencerangeC\">N/A - 500,000</td>\n <td></td>\n <td>06/22/2015</td>\n </tr>\n <tr>\n <td ID=\"resultD\">PLT</td>\n <td ID=\"resultvalueD\">123 (10*3/uL)</td>\n <td ID=\"referencerangeD\"></td>\n <td></td>\n <td>06/22/2015</td>\n </tr>\n <tr>\n <td ID=\"resultE\">Everolimus Blood</td>\n <td ID=\"resultvalueE\">10 ng/mL</td>\n <td ID=\"referencerangeE\">3.0-8.0 ng/ml</td>\n <td></td>\n <td>06/22/2015</td>\n </tr>\n <!-- amb and inp results below -->\n <tr>\n <td ID=\"result2\">Color of Urine</td>\n <td ID=\"resultvalue2\">YELLOW</td>\n <td ID=\"referencerange2\">YELLOW</td>\n <td>Normal</td>\n <td>06/22/2015</td>\n </tr>\n <tr>\n <td ID=\"result3\">Appearance of Urine</td>\n <td ID=\"resultvalue3\">CLEAR</td>\n <td ID=\"referencerange3\">CLEAR</td>\n <td>Normal</td>\n <td>06/22/2015</td>\n </tr>\n <tr>\n <td ID=\"result4\">Specific gravity of Urine by Test strip</td>\n <td ID=\"resultvalue4\">1.015</td>\n <td ID=\"referencerange4\">1.005 ? 1.030</td>\n <td>Normal</td>\n <td>06/22/2015</td>\n </tr>\n <tr>\n <td ID=\"result5\">pH of Urine by Test strip</td>\n <td ID=\"resultvalue5\">5.0 [pH]</td>\n <td ID=\"referencerange5\">5.0-8.0</td>\n <td>Normal</td>\n <td>06/22/2015</td>\n </tr>\n <tr>\n <td ID=\"result6\">Glucose [Mass/volume] in urine by test strip</td>\n <td ID=\"resultvalue6\">50 mg/dL</td>\n <td ID=\"referencerange6\">Neg</td>\n <td></td>\n <td>06/22/2015</td>\n </tr>\n <tr>\n <td ID=\"result7\">Ketones [Mass/Volume] in urine by test strip</td>\n <td ID=\"resultvalue7\">Negative</td>\n <td ID=\"referencerange7\">Negative</td>\n <td>Normal</td>\n <td>06/22/2015</td>\n </tr>\n <tr>\n <td ID=\"result8\">Protein[Mass/Volume] in urine by test strip</td>\n <td ID=\"resultvalue8\">100 mg/dL</td>\n <td ID=\"referencerange8\">negative</td>\n <td></td>\n <td>06/22/2015</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:81b20fc9-49fd-33df-b6a3-42ed663b4365"
}, {
"reference" : "urn:uuid:8c7b7711-4ffe-b548-a29e-4ac2fea9d2a9"
} ],
"code" : {
"text" : "RESULTS",
"coding" : [ {
"code" : "30954-2",
"display" : "RESULTS",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "FUNCTIONAL STATUS",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Functional Category</th>\n <th>Effective Dates</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td ID=\"FUNC1\">Dependence on Cane</td>\n <td>May 01, 2005</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:5f15f437-65bf-eb50-3aef-93f0f88d6126"
} ],
"code" : {
"text" : "Functional Status",
"coding" : [ {
"code" : "47420-5",
"display" : "Functional Status",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "MENTAL STATUS",
"text" : {
"div" : "\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Status</th>\n <th>Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Amnesia</td>\n <td>May 05, 2005</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:13e97da9-d1b5-7691-c36c-32199b23a600"
} ],
"code" : {
"text" : "MENTAL STATUS",
"coding" : [ {
"code" : "10190-7",
"display" : "MENTAL STATUS",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "ASSESSMENTS",
"text" : {
"div" : "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.",
"status" : "generated"
},
"code" : {
"text" : "ASSESSMENTS",
"coding" : [ {
"code" : "51848-0",
"display" : "ASSESSMENTS",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "TREATMENT PLAN",
"text" : {
"div" : "\n <content styleCode=\"Bold\"> Hand-off Communication:</content>\n <br/>\n <br/>\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Planned Care</th>\n <th>Start Date</th>\n </tr>\n </thead>\n <tbody>\n <!-- Laboratory Tests -db -->\n <tr>\n <td>Urinanalysis macro (dipstick) panel</td>\n <td>June 29, 2015</td>\n </tr>\n <!-- Procedures -db -->\n <tr>\n <td>Immunosuppressive therapy</td>\n <td>July 1, 2015</td>\n </tr>\n <!-- Encounters -db -->\n <tr>\n <td>Schedule an appointment with Dr Seven after 1 week for Follow up with Outpatient facility for Immunosuppressive therapy.</td>\n <td>July 1, 2015</td>\n </tr>\n </tbody>\n </table>\n ",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:a5accdd9-f770-a662-b129-b4ca0571cd2c"
}, {
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}, {
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}, {
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Encounter/66fbf518-f24b-7819-c7d6-072df459eb10
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ALLERGIES AND ADVERSE REACTIONS (2 entries)
| Substance |
Reaction |
Severity |
Status |
|
Penicillin G
|
Hives
|
Moderate
|
Active |
|
Ampicillin
|
Hives
|
Moderate
|
Active |
AllergyIntolerance/36e3e930-7b14-11db-9fe1-0800200c9a66
{
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},
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},
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} ]
},
"url" : "http://onc.org/allergy-observation-value"
}, {
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},
"url" : "http://onc.org/allergy-act-code"
} ],
"recordedDate" : "1980-05-01",
"id" : "36e3e930-7b14-11db-9fe1-0800200c9a66",
"code" : {
"text" : "Penicillin G",
"coding" : [ {
"code" : "7980",
"display" : "Penicillin G",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"onsetDateTime" : "1980-05-01",
"reaction" : [ {
"manifestation" : [ {
"text" : "Hives",
"coding" : [ {
"code" : "247472004",
"display" : "Hives",
"system" : "http://snomed.info/sct"
} ]
} ],
"severity" : "moderate"
}, {
"manifestation" : [ {
"text" : "WARNING: unresolved ref #REACT_1.1.2D",
"coding" : [ {
"code" : "422587007",
"display" : "Nausea",
"system" : "http://snomed.info/sct"
} ]
} ],
"onset" : "2010-03-15",
"severity" : "mild"
} ]
}
AllergyIntolerance/b03805bd-2eb6-4ab8-a9ff-473c6653971a
{
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},
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},
"resourceType" : "AllergyIntolerance",
"extension" : [ {
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} ]
},
"url" : "http://onc.org/allergy-observation-value"
}, {
"valueCodeableConcept" : {
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"system" : "HL7ActClass"
} ]
},
"url" : "http://onc.org/allergy-act-code"
} ],
"recordedDate" : "1980-05-01",
"id" : "b03805bd-2eb6-4ab8-a9ff-473c6653971a",
"code" : {
"text" : "Ampicillin",
"coding" : [ {
"code" : "733",
"display" : "Ampicillin",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"onsetDateTime" : "1980-05-01",
"reaction" : [ {
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"coding" : [ {
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"display" : "Hives",
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} ]
} ],
"severity" : "moderate"
} ]
}
MEDICATIONS (12 entries)
| 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 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 |
MedicationAdministration/6c844c75-aa34-411c-b7bd-5e4a9f206f44
{
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MedicationAdministration/6c844c75-aa34-411c-b7bd-5e4a9f207f42
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MedicationAdministration/6c844c75-aa34-421c-b7bd-5e4a9f206f44
{
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}
MedicationAdministration/6c844c75-aa34-411c-b7bd-5e4a9f216f43
{
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MedicationAdministration/6c844c75-aa34-412c-b7bd-5e4a9f206f42
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MedicationAdministration/6c844c75-aa34-422c-b7bd-5e4a9f206f44
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MedicationAdministration/6c844c75-aa34-423c-b7bd-5e4a9f206f44
{
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Discharge Medications (0 entries)
PROBLEMS (6 entries)
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)
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ENCOUNTERS (1 entries)
| Encounter Diagnosis |
Location |
Date |
| Anemia in Chronic Kidney Disease |
Community Health and Hospitals |
June 22, 2015 at 8:00am |
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ADMISSION DIAGNOSIS (1 entries)
Anemia
Condition/5a784260-6856-4f38-9638-80c751aff2fb
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PROCEDURES (3 entries)
| 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 |
Procedure/d68b7e32-7812-4f5b-9cc2-acd54b0fd85d
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Procedure/d68b7e32-7810-4f5b-9cc2-acd54b0fd85e
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Implants (1 entries)
| Implanted |
Area |
UDI |
| Cardiac Pacemaker |
Subclavian Vein |
(01)00643169007222(17)160128(21)BLC200461H |
Procedure/bee16ebf-3dce-08a6-3985-65f8d5ab066b
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IMMUNIZATIONS (3 entries)
| Vaccine |
Date |
Status |
Series number |
|
Influenza Virus Vaccine
|
May 10, 2014 |
Completed |
N/A |
|
Tetanus and diphtheria toxoids
|
January 4, 2012 |
Completed |
N/A |
|
influenza, intradermal, quadrivalent, preservative free
|
June 22, 2015 |
Refused |
N/A |
Immunization/e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92
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"coding" : [ {
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"display" : "Tetanus and diphtheria toxoids",
"system" : "http://hl7.org/fhir/sid/cvx"
} ]
},
"resourceType" : "Immunization",
"primarySource" : false,
"status" : "completed",
"id" : "e6f1ba43-c0ed-4b9b-9f12-f436d8ad8f92",
"lotNumber" : "2",
"occurrenceDateTime" : "2012-01-04"
}
Immunization/de10790f-1496-4719-8fe6-f1b88b6219f7
{
"patient" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization" ]
},
"vaccineCode" : {
"coding" : [ {
"code" : "166",
"display" : "influenza, intradermal, quadrivalent, preservative free",
"system" : "http://hl7.org/fhir/sid/cvx"
} ]
},
"statusReason" : {
"text" : "Patient Objection",
"coding" : [ {
"code" : "PATOBJ",
"display" : "Patient Objection",
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActReason"
} ]
},
"resourceType" : "Immunization",
"primarySource" : false,
"status" : "not-done",
"id" : "de10790f-1496-4719-8fe6-f1b88b6219f7",
"occurrenceDateTime" : "2015-06-22"
}
VITAL SIGNS (8 entries)
| 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 |
Observation/f4e729e2-a97f-4a7e-8e23-c92f9b6b55cf
{
"category" : [ {
"coding" : [ {
"code" : "vital-signs",
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"system" : "http://terminology.hl7.org/CodeSystem/observation-category"
} ]
} ],
"valueQuantity" : {
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"unit" : "kg"
},
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"status" : "final",
"id" : "f4e729e2-a97f-4a7e-8e23-c92f9b6b55cf",
"code" : {
"text" : "Patient Body Weight",
"coding" : [ {
"code" : "29463-7",
"display" : "Patient Body Weight",
"system" : "http://loinc.org"
} ]
},
"issued" : "2015-06-22T00:00:00Z",
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}
Observation/a0e39c70-9674-4b2a-9837-cdf74200d8d5
{
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"id" : "a0e39c70-9674-4b2a-9837-cdf74200d8d5",
"code" : {
"text" : "Intravascular Systolic",
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"display" : "Intravascular Systolic",
"system" : "http://loinc.org"
} ]
},
"issued" : "2015-06-22T00:00:00Z",
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} ]
}
Observation/a0e39c70-9675-4b2a-9838-cdf74200d8d5
{
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"valueQuantity" : {
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"unit" : "/min"
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"id" : "a0e39c70-9675-4b2a-9838-cdf74200d8d5",
"code" : {
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"coding" : [ {
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"display" : "Heart Rate",
"system" : "http://loinc.org"
} ]
},
"subject" : {
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}
}
Observation/1c2748b7-e440-41ba-bc01-dde97d84a036
{
"category" : [ {
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"code" : "vital-signs",
"display" : "Vital Signs",
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"valueQuantity" : {
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"unit" : "mm[Hg]"
},
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"status" : "final",
"id" : "1c2748b7-e440-41ba-bc01-dde97d84a036",
"code" : {
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"coding" : [ {
"code" : "8462-4",
"display" : "BP Diastolic",
"system" : "http://loinc.org"
} ]
},
"issued" : "2015-06-22T00:00:00Z",
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} ]
}
Observation/ed9589fd-fda0-41f7-a3d0-dc537554f5c2
{
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"code" : {
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},
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} ]
}
Observation/a0e39c70-9675-4b2a-9839-cdf74200d8d5
{
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"valueQuantity" : {
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"unit" : "%"
},
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"id" : "a0e39c70-9675-4b2a-9839-cdf74200d8d5",
"code" : {
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} ]
},
"subject" : {
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}
}
Observation/a0e39c70-9675-4b2a-9842-cdf74200d8d5
{
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} ],
"valueQuantity" : {
"value" : 18,
"unit" : "/min"
},
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"effectiveDateTime" : "2015-06-22T10:15:00-05:00",
"id" : "a0e39c70-9675-4b2a-9842-cdf74200d8d5",
"code" : {
"text" : "Respiratory Rate",
"coding" : [ {
"code" : "9279-1",
"display" : "Respiratory Rate",
"system" : "http://loinc.org"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Observation/a0e39c70-9675-4b2a-9841-cdf74200d8d5
{
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"valueQuantity" : {
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"unit" : "Cel"
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"id" : "a0e39c70-9675-4b2a-9841-cdf74200d8d5",
"code" : {
"text" : "Body Temperature",
"coding" : [ {
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"display" : "Body Temperature",
"system" : "http://loinc.org"
} ]
},
"subject" : {
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}
}
SOCIAL HISTORY (5 entries)
| Social History Observation |
Description |
Dates Observed |
| Smoking Status |
Heavy tobacco smoker, ??-??/day |
May 1, 2005 - February 27, 2011 |
| Current Smoking Status |
Current every day |
June 22, 2015 |
| Birth Sex |
Female |
June 22, 2015 |
Observation/45efb604-7049-4a2e-ad33-d38556c9636c
{
"category" : [ {
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} ],
"valueCodeableConcept" : {
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} ]
},
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"end" : "2011-02-27"
},
"id" : "45efb604-7049-4a2e-ad33-d38556c9636c",
"code" : {
"text" : "History of tobacco use",
"coding" : [ {
"code" : "11367-0",
"display" : "History of tobacco use",
"system" : "http://loinc.org"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Observation/3155d06c-8932-f32f-7040-a2ccd1a9b717
{
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} ]
} ],
"valueCodeableConcept" : {
"text" : "Current every day smoker",
"coding" : [ {
"code" : "449868002",
"display" : "Current every day smoker",
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} ]
},
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"status" : "final",
"effectiveDateTime" : "2015-06-22",
"id" : "3155d06c-8932-f32f-7040-a2ccd1a9b717",
"code" : {
"text" : "Tobacco smoking status NHIS",
"coding" : [ {
"code" : "72166-2",
"display" : "Tobacco smoking status NHIS",
"system" : "http://loinc.org"
} ]
},
"subject" : {
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}
}
Observation/b1bf3416-3291-42e8-4b84-2449032f5ab5
{
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"display" : "Social History",
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} ],
"resourceType" : "Observation",
"note" : [ {
"text" : "WARNING: unresolved ref #_6e185602-f807-40c6-8003-41c589ae62af"
} ],
"status" : "final",
"id" : "b1bf3416-3291-42e8-4b84-2449032f5ab5",
"code" : {
"text" : "WARNING: unresolved ref #_4503c511-8e06-41a0-8f6b-3f5d23b131e2",
"coding" : [ {
"code" : "76691-5",
"display" : "Gender identity",
"system" : "http://loinc.org"
} ]
},
"valueCodeableConcept" : {
"text" : "WARNING: unresolved ref #_71d1b8e1-b3dd-483f-80f3-49656e518994",
"coding" : [ {
"code" : "407377005",
"display" : "Female-to-male transsexual",
"system" : "http://snomed.info/sct"
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},
"issued" : "2014-06-06T10:32:00-05:00",
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
},
"performer" : [ {
"reference" : "urn:uuid:e3328330-e073-c7b4-c221-6a6dd9d7b21f"
} ],
"effectivePeriod" : {
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}
}
Observation/3e5c1aa7-09ef-0058-04ed-644f5080414e
{
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} ],
"valueCodeableConcept" : {
"text" : "Female",
"coding" : [ {
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"display" : "Female",
"system" : "urn:oid:2.16.840.1.113883.5.1"
} ]
},
"resourceType" : "Observation",
"note" : [ {
"text" : "Birth Sex"
} ],
"status" : "final",
"id" : "3e5c1aa7-09ef-0058-04ed-644f5080414e",
"code" : {
"text" : "Sex Assigned At Birth",
"coding" : [ {
"code" : "76689-9",
"display" : "Sex Assigned At Birth",
"system" : "http://loinc.org"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Observation/0c14d19f-8158-b955-5bae-bd72067be64a
{
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"display" : "Social History",
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} ],
"resourceType" : "Observation",
"note" : [ {
"text" : "WARNING: unresolved ref #_a1305452-cddd-4654-980f-bba6745588c8"
} ],
"status" : "final",
"id" : "0c14d19f-8158-b955-5bae-bd72067be64a",
"code" : {
"text" : "WARNING: unresolved ref #_3b8a5051-3968-4cfe-ab70-8b69f84bd378",
"coding" : [ {
"code" : "76690-7",
"display" : "Sexual orientation",
"system" : "http://loinc.org"
} ]
},
"valueCodeableConcept" : {
"text" : "WARNING: unresolved ref #_12d30bb3-f589-4d3b-a011-4b463aafa093",
"coding" : [ {
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"display" : "Bisexual",
"system" : "http://snomed.info/sct"
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},
"issued" : "2014-06-06T00:00:00Z",
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}
RESULTS (2 entries)
| 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 |
Observation/7d5a02b0-67a4-11db-bd13-0800221c9a23
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"id" : "7d5a02b0-67a4-11db-bd13-0800221c9a23",
"code" : {
"text" : "CBC",
"coding" : [ {
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"display" : "CBC",
"system" : "http://loinc.org"
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},
"status" : "final",
"category" : [ {
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"display" : "Laboratory",
"system" : "http://terminology.hl7.org/CodeSystem/observation-category"
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} ],
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Observation/7d5a02b0-67a4-11db-bd13-0800222c9a66
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} ],
"id" : "7d5a02b0-67a4-11db-bd13-0800222c9a66",
"code" : {
"text" : "Urinalysis macro panel",
"coding" : [ {
"code" : "24357-6",
"display" : "Urinalysis macro panel",
"system" : "http://loinc.org"
} ]
},
"status" : "final",
"category" : [ {
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FUNCTIONAL STATUS (1 entries)
| Functional Category |
Effective Dates |
| Dependence on Cane |
May 01, 2005 |
Observation/a7bc1062-8649-42a0-833d-eed65bd017c9
{
"resourceType" : "Observation",
"hasMember" : [ {
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"id" : "a7bc1062-8649-42a0-833d-eed65bd017c9",
"code" : {
"text" : "Self-Care",
"coding" : [ {
"code" : "d5",
"display" : "Self-Care",
"system" : "http://hl7.org/fhir/sid/icf"
} ]
},
"status" : "final",
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
MENTAL STATUS (1 entries)
| Status |
Date |
| Amnesia |
May 05, 2005 |
Observation/a7bc1062-8649-42a0-833d-ekd65bd013d1
{
"valueCodeableConcept" : {
"text" : "Amnesia",
"coding" : [ {
"code" : "48167000",
"display" : "Amnesia",
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} ]
},
"resourceType" : "Observation",
"status" : "final",
"effectivePeriod" : {
"start" : "2005-05-01"
},
"id" : "a7bc1062-8649-42a0-833d-ekd65bd013d1",
"code" : {
"text" : "Cognitive function",
"coding" : [ {
"code" : "373930000",
"display" : "Cognitive function",
"system" : "http://snomed.info/sct"
}, {
"code" : "75275-8",
"display" : "Cognitive function",
"system" : "http://loinc.org"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
ASSESSMENTS (0 entries)
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 (3 entries)
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 |
Procedure/9a6d1bac-17d3-4195-89c4-1121bc809b5a
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"code" : {
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},
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}
Encounter/2.3.7.1.42424242.5.11111.1.1.1
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"resourceType" : "Encounter",
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"id" : "2.3.7.1.42424242.5.11111.1.1.1",
"class" : {
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"system" : "http://terminology.hl7.org/ValueSet/v3-ActEncounterCode"
},
"period" : {
"start" : "2015-07-01"
},
"subject" : {
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}
Observation/b52bee94-c34b-4e2c-8c15-5ad9d6def513
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"effectiveDateTime" : "2015-06-29",
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"code" : {
"text" : "Urinanalysis macro (dipstick) panel",
"coding" : [ {
"code" : "24357-6",
"display" : "Urinanalysis macro (dipstick) panel",
"system" : "http://loinc.org"
} ]
},
"subject" : {
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}
}
Goals Section (2 entries)
| 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 |
Goal/3700b3b0-fbed-11e2-b778-0800200c9a66
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"target" : [ {
"detailString" : "Need to gain more energy to do regular activities. (Visual Inspection)",
"measure" : {
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},
"dueDate" : "2015-06-23"
} ],
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
},
"lifecycleStatus" : "active"
}
Goal/3700b3b0-fbed-12e2-b778-0800200c9a66
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"unit" : "[degF]"
},
"high" : {
"value" : 99,
"unit" : "[degF]"
}
},
"measure" : {
"text" : "Negotiated Goal for Body Temperature",
"coding" : [ {
"code" : "8310-5",
"display" : "Negotiated Goal for Body Temperature",
"system" : "http://loinc.org"
} ]
},
"dueDate" : "2015-06-23"
} ],
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},
"lifecycleStatus" : "active"
}
Health Concerns Section (2 entries)
| 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 |
List/4eab0e52-dd7d-4285-99eb-72d32ddb195c
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"mode" : "snapshot",
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Observation/1eeb1e51-ee1d-1234-11xy-11z11ddb111z
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HOSPITAL DISCHARGE INSTRUCTIONS (0 entries)
- Diet: Diabetic low salt diet
- Medications: Take prescribed medications as advised.
- Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility for Immunosuppression treatment.
- For Fever of > 101.5 F, or onset of chest pain/breathlessness contact Emergency.
HOSPITAL COURSE (0 entries)
Ms. Rabecca Angeles is a 45 year old female with a history of Hypertension, Hypothyroidism, Iron deficiency and is a recipient of Renal Allograft is admitted on 6/22/2015 at 10 am EST to Community Health and Hospitals with history of intermittent fever for 2 days. The patient disclosed history of nausea, loose stools and weakness. She was found to have Anemia secondary to iron deficiency and CKD. After conducting multiple tests and administering necessary medications, the patient was discharged to Ambulatory facility to follow up with immunosuppression as an out-patient. The condition of the patient at discharge was stable, with controlled blood sugar levels and a pain score below 3. Additional follow up instructions have been provided to the patient.
Discharge Diagnosis (0 entries)
The patient was discharged to Ambulatory facility to follow up with immunosuppression as an out-patient. The condition of the patient at discharge was stable, with controlled blood sugar levels and a pain score below 3. Additional follow up instructions have been provided to the patient.
