170.315_b1_toc_inp_ds_r21_sample1 test data
Rabecca Angeles
Patient Identifiers
118283339 United States Social Security Number

About

Date of Birth
07/1/1970
Sex
Female
Race
White
Ethnicity
Mexican

Contact

Primary Home

1007 Amber Dr 1002 Oak Dr

Beaverton, OR

97266, US

Tel : +1(555)-225-1234

Care provision

Anemia from 06/22/2015 to 06/24/2015

Service Event

Dr Henry Seven of Community Health and Hospitals
06/22/2015 - 06/24/2015

Service Event

Mary McDonald
06/22/2015 - 06/24/2015

Author

Dr Henry Seven

Contact

1002 Healthcare Dr

Beaverton, OR

97266, US

Tel : +1(555)-555-1002

Encounter

Identifier
9937012 OID: 2.16.840.1.113883.19
Date
From: 06/22/2015, 10:00
To: 06/24/2015

Personal relationship

Mr Issac Wilmer

Contact

Primary Home

1007 Amber Dr

Beaverton, OR

97266, US

Tel : +1(555)-226-1544

Personal relationship

Mr Richard Angeles

Contact

Primary Home

1007 Amber Dr

Beaverton, OR

97266, US

Tel : +1(555)-226-1544

Informant

Henry Seven

Contact

1002 Healthcare Dr

Beaverton, OR

97266, US

Tel : +1(555)-555-1002

Informant

Richard Angeles

Information Recipient

Dr Henry Seven

Legal authenticator

Dr Henry Seven signed at 06/22/2015

Contact

1002 Healthcare Dr

Beaverton, OR

97266, US

Tel : +1(555)-555-1002

Problem List

Name Dates Status
Community Acquired Pneumonia Onset: February 27 2014 Active

Signed

Dr Henry Seven at 06/22/2015

Contact

1002 Healthcare Dr

Beaverton, OR

97266, US

Tel : +1(555)-555-1002

Document maintained by

Community Health and Hospitals

Contact

Work Place

1002 Healthcare Dr

Beaverton, OR

97266, US

Tel : +1(555)-555-1002

Entered by

Mary McDonald

Contact

1002 Healthcare Dr

Beaverton, OR

97266, US

Tel : +1(555)-555-1002

Document Information

Document Identifier Document Created
TT107 OID: 2.16.840.1.113883.19.5.99999.1 06/22/2015