Header
Composition/ee05e1da-df1b-7f7e-166c-e182e1d39f86
{
"date" : "2023-02-02",
"encounter" : {
"reference" : "urn:uuid:d6c3788c-ed93-1199-a863-346caccfa5e4"
},
"section" : [ {
"title" : "Medications",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\n<caption>\nMedications List\n</caption>\n<thead>\n<tr>\n<th>\nMedication\n</th>\n<th>\nTiming\n</th>\n<th>\nRoute\n</th>\n<th>\nFreq\n</th>\n<th>\nDose\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nTylenol 500mg\n</td>\n<td>\n~\n</td>\n<td>\nOral\n</td>\n<td>\nOral, as needed, 1 unit\n</td>\n<td>\n1 \n</td>\n</tr>\n<tr>\n<td>\nAranesp 0.5 MG/ML\n</td>\n<td>\n~\n</td>\n<td>\nInjection\n</td>\n<td>\nInjectable, once a week, 1 unit\n</td>\n<td>\n1 \n</td>\n</tr>\n<tr>\n<td>\nClindamycin 300mg\n</td>\n<td>\n06/23/2015 12:00AM UTC - 06/30/2015 12:00AM UTC\n</td>\n<td>\nOral\n</td>\n<td>\nOral, three times daily, 1 unit\n</td>\n<td>\n1 \n</td>\n</tr>\n<tr>\n<td>\nTorsemide 20mg\n</td>\n<td>\n06/23/2015 12:00AM UTC - 06/30/2015 12:00AM UTC\n</td>\n<td>\nOral\n</td>\n<td>\nOral, daily, 1 unit\n</td>\n<td>\n1 \n</td>\n</tr>\n<tr>\n<td>\nFenoFibric Acid 35 mg\n</td>\n<td>\n06/24/2015 12:00AM UTC - 07/04/2015 12:00AM UTC\n</td>\n<td>\nOral\n</td>\n<td>\nAt the hour of sleep\n</td>\n<td>\n1 \n</td>\n</tr>\n<tr>\n<td>\nMycophenolic Acid 360mg\n</td>\n<td>\n06/24/2015 12:00AM UTC - 06/27/2015 12:00AM UTC\n</td>\n<td>\nOral\n</td>\n<td>\nOral, two times daily, 1 unit\n</td>\n<td>\n1 \n</td>\n</tr>\n<tr>\n<td>\nEverolimus 0.5mg\n</td>\n<td>\n06/24/2015 12:00AM UTC - 07/20/2015 12:00AM UTC\n</td>\n<td>\nOral\n</td>\n<td>\nOral, two times daily, 1 unit\n</td>\n<td>\n1 \n</td>\n</tr>\n<tr>\n<td>\nCiprofloxacin 250mg\n</td>\n<td>\n06/24/2015 12:00AM UTC - 07/24/2015 12:00AM UTC\n</td>\n<td>\nOral\n</td>\n<td>\nOral, three times daily, 1 unit\n</td>\n<td>\n1 \n</td>\n</tr>\n<tr>\n<td>\nCeftriaxone 100 MG/ML\n</td>\n<td>\n~\n</td>\n<td>\nInjection\n</td>\n<td>\n~\n</td>\n<td>\n1 \n</td>\n</tr>\n</tbody>\n</table>\n<table width='100%' border='1'>\n<caption>\nAdministered Medications\n</caption>\n<thead>\n<tr>\n<th>\nMedication\n</th>\n<th>\nDate\n</th>\n<th>\nRoute\n</th>\n<th>\nDose\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nNo records\n</td>\n</tr>\n</tbody>\n</table>\n</div>\n",
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},
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"reference" : "urn:uuid:2f377179-7333-f5f4-eb89-ef7fb9992084"
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"code" : {
"text" : "History of Medication use",
"coding" : [ {
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"display" : "History of Medication use",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Allergies and Intolerances",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\n<thead>\n<tr>\n<th>\nType\n</th>\n<th>\nSubstance\n</th>\n<th>\nOnset\n</th>\n<th>\nReactions\n</th>\n<th>\nStatus\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nallergy\n</td>\n<td>\nAmpicillin\n</td>\n<td>\n05/10/1980 12:00AM UTC\n</td>\n<td>\n05/10/1980 12:00AM UTC - Hives - moderate\n</td>\n<td>\nactive\n</td>\n</tr>\n<tr>\n<td>\nN/A\n</td>\n<td>\nPenicillin G\n</td>\n<td>\n05/10/1980 12:00AM UTC\n</td>\n<td>\n05/10/1980 12:00AM UTC - Hives - moderate\n</td>\n<td>\nactive\n</td>\n</tr>\n</tbody>\n</table>\n</div>\n",
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},
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"code" : {
"text" : "Allergies",
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"code" : "48765-2",
"display" : "Allergies",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Consultation Notes",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Consultation Notes\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Consultation note",
"coding" : [ {
"code" : "11488-4",
"display" : "Consultation note",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Encounters",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\n<thead>\n<tr>\n<th>\nDate\n</th>\n<th>\nType\n</th>\n<th>\nDepartment\n</th>\n<th>\nCareTeam\n</th>\n<th>\nDescription\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nNo records\n</td>\n</tr>\n</tbody>\n</table>\n</div>\n",
"status" : "generated"
},
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"code" : {
"text" : "Encounters",
"coding" : [ {
"code" : "46240-8",
"display" : "Encounters",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Immunizations",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\n<thead>\n<tr>\n<th>\nVaccine\n</th>\n<th>\nDate\n</th>\n<th>\nStatus\n</th>\n<th>\nLot\n</th>\n<th>\nNotes\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nTetanus and diphtheria toxoids\n</td>\n<td>\n01/04/2012 12:00AM UTC\n</td>\n<td>\ncompleted\n</td>\n<td>\nN/A\n</td>\n<td>\nImmunization was not given - Patient rejected immunization\n</td>\n</tr>\n<tr>\n<td>\nInfluenza, intradermal, quadrivalent, preservative-free\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n<td>\nnot-done\n</td>\n<td>\nNo Lot number provided\n</td>\n<td>\nImmunization was not given - Patient rejected immunization\n</td>\n</tr>\n</tbody>\n</table>\n</div>\n",
"status" : "generated"
},
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"reference" : "urn:uuid:4563330c-19a4-70d6-edd2-3f9ba865de7f"
}, {
"reference" : "urn:uuid:32cbec8b-79d2-ad29-5d9d-2cede9065931"
} ],
"code" : {
"text" : "History of Immunization Narrative",
"coding" : [ {
"code" : "11369-6",
"display" : "History of Immunization Narrative",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Mental Status",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Mental Status\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Mental Status Narrative",
"coding" : [ {
"code" : "10190-7",
"display" : "Mental Status Narrative",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Problems",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\n<caption>\nActive Problems\n</caption>\n<thead>\n<tr>\n<th>\nProblem\n</th>\n<th>\nNoted Date\n</th>\n<th>\nDiagnosed Date\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nSevere hypothyroidism\n</td>\n<td>\n12/31/2006 12:00AM UTC\n</td>\n<td>\n~\n</td>\n</tr>\n<tr>\n<td>\nChronic rejection of renal transplant\n</td>\n<td>\n12/31/2011 12:00AM UTC\n</td>\n<td>\n~\n</td>\n</tr>\n<tr>\n<td>\nIron deficiency anemia\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n<td>\n~\n</td>\n</tr>\n<tr>\n<td>\nInterstitial pneumonia\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n<td>\n~\n</td>\n</tr>\n<tr>\n<td>\nEssential hypertension\n</td>\n<td>\n05/10/2015 12:00AM UTC\n</td>\n<td>\n~\n</td>\n</tr>\n</tbody>\n</table>\n<table width='100%' border='1'>\n<caption>\nResolved Problems\n</caption>\n<thead>\n<tr>\n<th>\nProblem\n</th>\n<th>\nNoted Date\n</th>\n<th>\nDiagnosed Date\n</th>\n<th>\nResolved Date\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nOverweight\n</td>\n<td>\n12/31/2006 12:00AM UTC\n</td>\n<td>\n~\n</td>\n<td>\n06/01/2007 12:00AM UTC\n</td>\n</tr>\n</tbody>\n</table>\n</div>\n",
"status" : "generated"
},
"extension" : [ {
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"entry" : [ {
"reference" : "urn:uuid:cea7cc62-e039-327a-167f-eff8ccdd2117"
}, {
"reference" : "urn:uuid:63112894-558f-f990-d788-29a8ef3d9fe6"
}, {
"reference" : "urn:uuid:4f9752c7-2c2a-089c-a343-62b13917ba78"
}, {
"reference" : "urn:uuid:04c11196-6579-419a-cbb6-9126a300279e"
}, {
"reference" : "urn:uuid:748d5b03-c898-78b4-4ae6-3b368b02c0b2"
}, {
"reference" : "urn:uuid:1ace5845-3798-7823-7607-f24bb8e6fb91"
} ],
"code" : {
"text" : "Problems",
"coding" : [ {
"code" : "11450-4",
"display" : "Problems",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Goals",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\na. Need to gain more energy to do regular activities.\nb. Negotiated Goal to keep Body Temperature at 98-99 degrees Fahrenheit with regular\nmonitoring\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Goals",
"coding" : [ {
"code" : "61146-7",
"display" : "Goals",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Functional Status",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Functional Status\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Functional Status",
"coding" : [ {
"code" : "47420-5",
"display" : "Functional Status",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Discharge Summary",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Discharge Summary\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Discharge Summary",
"coding" : [ {
"code" : "18842-5",
"display" : "Discharge Summary",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Progress Notes",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<caption>\nHenry Seven - 06/22/2015 12:00AM UTC\n</caption>\nMs Rebecca Larson got admitted due to developing high fever and since has shown considerable\nimprovement and can be discharged shortly.\n</div>\n",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:ba06c7b1-e03b-a744-9bde-b6c049e49476"
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"code" : {
"text" : "Progress Note",
"coding" : [ {
"code" : "11506-3",
"display" : "Progress Note",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Medical Equipment",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\n<thead>\n<tr>\n<th>\nID\n</th>\n<th>\nAssigning Auth\n</th>\n<th>\nCode\n</th>\n<th>\nDate\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\n(01)00643169007222(17)160128(21)BLC200461H\n</td>\n<td>\nFDA\n</td>\n<td>\nCardiac resynchronization therapy implantable pacemaker\n</td>\n<td>\n10/05/2011 12:00AM UTC\n</td>\n</tr>\n</tbody>\n</table>\n</div>\n",
"status" : "generated"
},
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} ],
"code" : {
"text" : "History of Medical Device Use",
"coding" : [ {
"code" : "46264-8",
"display" : "History of Medical Device Use",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Discharge Instructions",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\na. Diet: Diabetic low salt diet\nb. Medications: Take prescribed medications as advised.\nc. Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up\nwith Outpatient facility for Immunosuppression treatment.\nd. For Fever of > 101.5 F, or onset of chest pain/breathlessness contact Emergency.\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Discharge instructions",
"coding" : [ {
"code" : "8653-8",
"display" : "Discharge instructions",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Procedures",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\n<thead>\n<tr>\n<th>\nProcedures\n</th>\n<th>\nDate\n</th>\n<th>\nStatus\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nBronchoscopy\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n<td>\ncompleted\n</td>\n</tr>\n<tr>\n<td>\nChest X-Ray, PA and Lateral Views\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n<td>\ncompleted\n</td>\n</tr>\n<tr>\n<td>\nIntroduction of cardiac pacemaker system via vein\n</td>\n<td>\n10/05/2011 12:00AM UTC\n</td>\n<td>\ncompleted\n</td>\n</tr>\n</tbody>\n</table>\n</div>\n",
"status" : "generated"
},
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"entry" : [ {
"reference" : "urn:uuid:e6f51902-ed1d-4c9c-1ea0-7700f99456e5"
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"reference" : "urn:uuid:3d6268e8-ea91-1319-a885-b208f36fbbe6"
}, {
"reference" : "urn:uuid:62584a0a-793c-4846-e92d-7f2a7a2bce7f"
} ],
"code" : {
"text" : "History of Procedures Document",
"coding" : [ {
"code" : "47519-4",
"display" : "History of Procedures Document",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "History And Physical Notes",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section History And Physical Notes\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "History And Physical Note",
"coding" : [ {
"code" : "34117-2",
"display" : "History And Physical Note",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Social History",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\n<thead>\n<tr>\n<th>\nElement\n</th>\n<th>\nDate\n</th>\n<th>\nValue\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nTobacco smoking status NHIS\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n<td>\nCurrent every day smoker\n</td>\n</tr>\n<tr>\n<td>\nSex Assigned At Birth\n</td>\n<td>\n~\n</td>\n<td>\nFemale\n</td>\n</tr>\n</tbody>\n</table>\n</div>\n",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:bff8d2d0-493b-357f-bf50-68bc353f15da"
}, {
"reference" : "urn:uuid:391d399b-f9c4-36eb-2943-ce5e0a189e32"
} ],
"code" : {
"text" : "Social History",
"coding" : [ {
"code" : "29762-2",
"display" : "Social History",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Assesments",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nThe patient was found to have Anemia and Dr Seven and his staff diagnosed\nthe condition and treated Ms Rebecca for Anemia during the 2 day stay at\nCommunity Health Hospitals. Ms Rebecca recovered from Anemia during\nthe stay and is being discharged in a stable condition. If there is fever\ngreater than 101.5 F or onset of chest pain/breathlessness the patient is\nadvised to contact emergency\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Assessments",
"coding" : [ {
"code" : "51848-0",
"display" : "Assessments",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Health Concerns",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\na. Chronic Sickness exhibited by patient\nb. HealthCare Concerns refer to underlying clinical facts\ni. Documented HyperTension problem\nii. Documented HypoThyroidism problem\niii. Watch Weight of patient\niv. Documented Anemia problem\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Health Concerns",
"coding" : [ {
"code" : "75310-3",
"display" : "Health Concerns",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Hospital Course",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nMs. Rebecca Larson is a 45 year old female with a history of Hypertension, Hypothyroidism, Iron\ndeficiency and is a recipient of Renal Allograft is admitted on 6/22/2015 at 10 am EST to Community\nHealth and Hospitals with history of intermittent fever for 2 days. The patient disclosed history of\nnausea, loose stools and weakness. She was found to have Anemia secondary to iron deficiency and\nCKD. After conducting multiple tests and administering necessary medications, the patient was\ndischarged to Ambulatory facility to follow up with immunosuppression as an out-patient. The\ncondition of the patient at discharge was stable, with controlled blood sugar levels and a pain score\nbelow 3. Additional follow up instructions have been provided to the patient. \n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Hospital course Narrative",
"coding" : [ {
"code" : "8648-8",
"display" : "Hospital course Narrative",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Laboratory Notes",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<caption>\nHenry Seven - 06/22/2015 12:00AM UTC\n</caption>\nMs Rebecca Larson was tested for the Urinanalysis macro panel and CBC and the results have been\nfound to be normal.\n</div>\n",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:cdb9a0c6-9e84-56d2-2dce-6b8edcff01d9"
} ],
"code" : {
"text" : "Laboratory Report",
"coding" : [ {
"code" : "11502-2",
"display" : "Laboratory Report",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Results",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<caption>\nUrinanalysis macro (dipstick) panel, No performer ID, No Lab, No Lab Address\n</caption>\n<table width='100%' border='1'>\n<thead>\n<tr>\n<th>\nCode\n</th>\n<th>\nValue\n</th>\n<th>\nDate\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nColor of urine\n</td>\n<td>\nYELLOW\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n<tr>\n<td>\nAppearance of urine\n</td>\n<td>\nCLEAR\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n<tr>\n<td>\nSpecific gravity of urine by test strip\n</td>\n<td>\n1.015 1\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n<tr>\n<td>\npH of Urine by Test strip\n</td>\n<td>\n5.0 [pH]\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n<tr>\n<td>\nGlucose [Mass/volume] in urine by test strip\n</td>\n<td>\n50 mg/dL\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n<tr>\n<td>\nKetones [Mass/Volume] in urine by test strip\n</td>\n<td>\nNegative\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n<tr>\n<td>\nProtein [Mass/Volume] in urine by test strip\n</td>\n<td>\n100 mg/dL\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n</tbody>\n</table>\n<caption>\nCBC, No performer ID, No Lab, No Lab Address\n</caption>\n<table width='100%' border='1'>\n<thead>\n<tr>\n<th>\nCode\n</th>\n<th>\nValue\n</th>\n<th>\nDate\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nHGB\n</td>\n<td>\n10.2 g/dL\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n<tr>\n<td>\nWBC\n</td>\n<td>\n12.3 10*3/uL\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n<tr>\n<td>\nPLT\n</td>\n<td>\n123 10*3/ul\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n<tr>\n<td>\nEverolimus Blood\n</td>\n<td>\n10 ng/mL\n</td>\n<td>\n06/22/2015 12:00AM UTC\n</td>\n</tr>\n</tbody>\n</table>\n</div>\n",
"status" : "generated"
},
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"code" : {
"text" : "Results",
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"code" : "30954-2",
"display" : "Results",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Plan of treatment",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\ni. Schedule an appointment with Dr Seven after 1 week for Follow up with\nOutpatient facility for Immunosuppressive therapy.\n</div>\n",
"status" : "generated"
},
"entry" : [ {
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} ],
"code" : {
"text" : "Plan of treatment",
"coding" : [ {
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"display" : "Plan of treatment",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Procedures Notes",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<caption>\nHenry Seven - 06/22/2015 12:00AM UTC\n</caption>\nDr Seven examined Ms Rebecca Larson and found that the pacemaker is operating properly and the\nbreathlessness is due to high fever and anxiety.\n</div>\n",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:bf9e437a-8a5b-7948-bad2-96ce584a2613"
} ],
"code" : {
"text" : "Procedures Note",
"coding" : [ {
"code" : "28570-0",
"display" : "Procedures Note",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Payers",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo data for section Payers\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Payment Sources Narrative",
"coding" : [ {
"code" : "48768-6",
"display" : "Payment Sources Narrative",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Vital Signs",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\n<thead>\n<tr>\n<th>\nVital sign\n</th>\n<th>\nDate\n</th>\n<th>\nValue and units\n</th>\n</tr>\n</thead>\n<tbody>\n<tr>\n<td>\nBlood Pressure Systolic\n</td>\n<td>\n06/22/2015 3:08PM UTC\n</td>\n<td>\n145 mm[Hg]\n</td>\n</tr>\n<tr>\n<td>\nBlood Pressure Diastolic\n</td>\n<td>\n06/22/2015 3:08PM UTC\n</td>\n<td>\n88 mm[Hg]\n</td>\n</tr>\n<tr>\n<td>\nHeart Rate\n</td>\n<td>\n06/22/2015 3:10PM UTC\n</td>\n<td>\n80 /min\n</td>\n</tr>\n<tr>\n<td>\nBody Temperature\n</td>\n<td>\n06/22/2015 3:15PM UTC\n</td>\n<td>\n38 Cel\n</td>\n</tr>\n<tr>\n<td>\nRespiratory Rate\n</td>\n<td>\n06/22/2015 3:15PM UTC\n</td>\n<td>\n18 /min\n</td>\n</tr>\n<tr>\n<td>\nO2 % BldC Oximetry\n</td>\n<td>\n06/22/2015 3:12PM UTC\n</td>\n<td>\n95 %\n</td>\n</tr>\n<tr>\n<td>\nInhaled Oxygen Concentration\n</td>\n<td>\n06/22/2015 3:12PM UTC\n</td>\n<td>\n36 %\n</td>\n</tr>\n<tr>\n<td>\nWeight\n</td>\n<td>\n06/22/2015 3:05PM UTC\n</td>\n<td>\n88 kg\n</td>\n</tr>\n<tr>\n<td>\nHeight\n</td>\n<td>\n06/22/2015 3:05PM UTC\n</td>\n<td>\n177 cm\n</td>\n</tr>\n<tr>\n<td>\nBMI\n</td>\n<td>\n~\n</td>\n<td>\n~\n</td>\n</tr>\n<tr>\n<td>\nHead Occipital Circumference\n</td>\n<td>\n~\n</td>\n<td>\n~\n</td>\n</tr>\n</tbody>\n</table>\n</div>\n",
"status" : "generated"
},
"extension" : [ {
"valueBoolean" : true,
"url" : "entries-required"
} ],
"entry" : [ {
"reference" : "urn:uuid:624617e3-6aea-40ac-2c87-a07f622fbddd"
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"reference" : "urn:uuid:e4b7937b-4e50-aa99-cffd-b3812c0b1268"
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"code" : {
"text" : "Vitals",
"coding" : [ {
"code" : "8716-3",
"display" : "Vitals",
"system" : "http://loinc.org"
} ]
}
} ],
"type" : {
"text" : "Summarization of Episode Note",
"coding" : [ {
"code" : "34133-9",
"display" : "Summarization of Episode Note",
"system" : "http://loinc.org"
} ]
},
"resourceType" : "Composition",
"title" : "Summarization of Episode Note",
"author" : [ {
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} ],
"custodian" : {
"reference" : "urn:uuid:63f4567c-487e-bf07-1867-f4b907251f43"
},
"status" : "final",
"id" : "ee05e1da-df1b-7f7e-166c-e182e1d39f86",
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Patient/patient
{
"address" : [ {
"line" : [ "1357 Amber Dr" ],
"use" : "home",
"city" : "Beaverton",
"state" : "OR",
"postalCode" : "97006",
"country" : "USA"
} ],
"name" : [ {
"given" : [ "Robin", "Jones" ],
"family" : "Larson",
"use" : "old"
}, {
"given" : [ "Rebecca", "Jones" ],
"family" : "Larson",
"use" : "official"
} ],
"birthDate" : "1970-05-01",
"resourceType" : "Patient",
"extension" : [ {
"extension" : [ {
"valueCoding" : {
"code" : "2106-3",
"display" : "White",
"system" : "urn:oid:2.16.840.1.113883.6.238"
},
"url" : "ombCategory"
}, {
"valueCoding" : {
"code" : "2108-9",
"display" : "White European",
"system" : "urn:oid:2.16.840.1.113883.6.238"
},
"url" : "detailed"
}, {
"valueString" : "White",
"url" : "text"
} ],
"url" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-race"
}, {
"extension" : [ {
"valueCoding" : {
"code" : "2186-5",
"display" : "Not Hispanic or Latino",
"system" : "urn:oid:2.16.840.1.113883.6.238"
},
"url" : "ombCategory"
}, {
"valueString" : "Not Hispanic or Latino",
"url" : "text"
} ],
"url" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity"
} ],
"communication" : [ {
"language" : {
"coding" : [ {
"code" : "en",
"display" : "en",
"system" : "urn:oid:"
} ]
},
"preferred" : true
} ],
"id" : "patient",
"telecom" : [ {
"system" : "phone",
"value" : "+1-555-777-1234",
"use" : "mobile"
}, {
"system" : "phone",
"value" : "+1-555-723-1544",
"use" : "home"
} ],
"gender" : "female",
"maritalStatus" : {
"coding" : [ {
"code" : "UNK",
"display" : "Unknown",
"system" : "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"
} ]
}
}
PractitionerRole/1d4a6865-54a5-63fb-0b62-203037254391
{
"practitioner" : {
"reference" : "urn:uuid:48a2209a-478c-fa48-2e15-51e323854be3"
},
"id" : "1d4a6865-54a5-63fb-0b62-203037254391",
"organization" : {
"reference" : "urn:uuid:63f4567c-487e-bf07-1867-f4b907251f43"
},
"resourceType" : "PractitionerRole",
"period" : {
"start" : "2015-06-22"
}
}
Encounter/07edd8a4-d933-6a04-c81b-3f9bd5a8ed81
{
"period" : {
"start" : "2015-06-22",
"end" : "2015-06-24"
},
"resourceType" : "Encounter",
"status" : "finished",
"class" : {
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code" : "AMB",
"display" : "AMB"
},
"id" : "07edd8a4-d933-6a04-c81b-3f9bd5a8ed81",
"participant" : [ {
"individual" : {
"reference" : "urn:uuid:cf44ec5a-c00d-e99d-1645-d044281d1151"
}
}, {
"individual" : {
"reference" : "urn:uuid:ada42cdd-ed1d-da17-4de7-267d7a3ffef6"
}
} ]
}
Medications (9 entries)
Medications List
|
Medication
|
Timing
|
Route
|
Freq
|
Dose
|
|
Tylenol 500mg
|
~
|
Oral
|
Oral, as needed, 1 unit
|
1
|
|
Aranesp 0.5 MG/ML
|
~
|
Injection
|
Injectable, once a week, 1 unit
|
1
|
|
Clindamycin 300mg
|
06/23/2015 12:00AM UTC - 06/30/2015 12:00AM UTC
|
Oral
|
Oral, three times daily, 1 unit
|
1
|
|
Torsemide 20mg
|
06/23/2015 12:00AM UTC - 06/30/2015 12:00AM UTC
|
Oral
|
Oral, daily, 1 unit
|
1
|
|
FenoFibric Acid 35 mg
|
06/24/2015 12:00AM UTC - 07/04/2015 12:00AM UTC
|
Oral
|
At the hour of sleep
|
1
|
|
Mycophenolic Acid 360mg
|
06/24/2015 12:00AM UTC - 06/27/2015 12:00AM UTC
|
Oral
|
Oral, two times daily, 1 unit
|
1
|
|
Everolimus 0.5mg
|
06/24/2015 12:00AM UTC - 07/20/2015 12:00AM UTC
|
Oral
|
Oral, two times daily, 1 unit
|
1
|
|
Ciprofloxacin 250mg
|
06/24/2015 12:00AM UTC - 07/24/2015 12:00AM UTC
|
Oral
|
Oral, three times daily, 1 unit
|
1
|
|
Ceftriaxone 100 MG/ML
|
~
|
Injection
|
~
|
1
|
Administered Medications
|
Medication
|
Date
|
Route
|
Dose
|
|
No records
|
MedicationStatement/5a789ca4-7f48-4d27-4fda-72650448fd30
{
"resourceType" : "MedicationStatement",
"medicationCodeableConcept" : {
"text" : "Everolimus 0.5mg",
"coding" : [ {
"code" : "977434",
"display" : "Everolimus 0.5mg",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"id" : "5a789ca4-7f48-4d27-4fda-72650448fd30",
"status" : "active",
"dosage" : [ {
"route" : {
"text" : "Oral",
"coding" : [ {
"code" : "C38288",
"display" : "Oral",
"system" : "http://ncithesaurus-stage.nci.nih.gov"
} ]
},
"text" : "Oral, two times daily, 1 unit",
"doseAndRate" : [ {
"doseQuantity" : {
"value" : 1.0
}
} ]
} ],
"effectivePeriod" : {
"start" : "2015-06-24",
"end" : "2015-07-20"
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
MedicationStatement/83c904e0-564f-a456-b740-961dd52ca76a
{
"resourceType" : "MedicationStatement",
"medicationCodeableConcept" : {
"text" : "Mycophenolic Acid 360mg",
"coding" : [ {
"code" : "485023",
"display" : "Mycophenolic Acid 360mg",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"id" : "83c904e0-564f-a456-b740-961dd52ca76a",
"status" : "active",
"dosage" : [ {
"route" : {
"text" : "Oral",
"coding" : [ {
"code" : "C38288",
"display" : "Oral",
"system" : "http://ncithesaurus-stage.nci.nih.gov"
} ]
},
"text" : "Oral, two times daily, 1 unit",
"doseAndRate" : [ {
"doseQuantity" : {
"value" : 1.0
}
} ]
} ],
"effectivePeriod" : {
"start" : "2015-06-24",
"end" : "2015-06-27"
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
MedicationStatement/1d29419f-8015-b19c-8b1f-f6c4be327837
{
"resourceType" : "MedicationStatement",
"medicationCodeableConcept" : {
"text" : "Tylenol 500mg",
"coding" : [ {
"code" : "209459",
"display" : "Tylenol 500mg",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"id" : "1d29419f-8015-b19c-8b1f-f6c4be327837",
"status" : "active",
"dosage" : [ {
"route" : {
"text" : "Oral",
"coding" : [ {
"code" : "C38288",
"display" : "Oral",
"system" : "http://ncithesaurus-stage.nci.nih.gov"
} ]
},
"text" : "Oral, as needed, 1 unit",
"doseAndRate" : [ {
"doseQuantity" : {
"value" : 1.0
}
} ]
} ],
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
MedicationStatement/d0a69d4d-a77c-d4db-b991-62847fc881f4
{
"resourceType" : "MedicationStatement",
"medicationCodeableConcept" : {
"text" : "Aranesp 0.5 MG/ML",
"coding" : [ {
"code" : "731241",
"display" : "Aranesp 0.5 MG/ML",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"id" : "d0a69d4d-a77c-d4db-b991-62847fc881f4",
"status" : "active",
"dosage" : [ {
"route" : {
"text" : "Injection",
"coding" : [ {
"code" : "C38276",
"display" : "Injection",
"system" : "http://ncithesaurus-stage.nci.nih.gov"
} ]
},
"text" : "Injectable, once a week, 1 unit",
"doseAndRate" : [ {
"doseQuantity" : {
"value" : 1.0
}
} ]
} ],
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
MedicationStatement/b270d9fa-a4d7-fdff-20f0-edc8ce118f62
{
"resourceType" : "MedicationStatement",
"medicationCodeableConcept" : {
"text" : "Ciprofloxacin 250mg",
"coding" : [ {
"code" : "197511",
"display" : "Ciprofloxacin 250mg",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"id" : "b270d9fa-a4d7-fdff-20f0-edc8ce118f62",
"status" : "active",
"dosage" : [ {
"route" : {
"text" : "Oral",
"coding" : [ {
"code" : "C38288",
"display" : "Oral",
"system" : "http://ncithesaurus-stage.nci.nih.gov"
} ]
},
"text" : "Oral, three times daily, 1 unit",
"doseAndRate" : [ {
"doseQuantity" : {
"value" : 1.0
}
} ]
} ],
"effectivePeriod" : {
"start" : "2015-06-24",
"end" : "2015-07-24"
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
MedicationStatement/74f7d1c1-3744-1d28-c6ac-63e33107dbc1
{
"resourceType" : "MedicationStatement",
"medicationCodeableConcept" : {
"text" : "FenoFibric Acid 35 mg",
"coding" : [ {
"code" : "860886",
"display" : "FenoFibric Acid 35 mg",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"id" : "74f7d1c1-3744-1d28-c6ac-63e33107dbc1",
"status" : "active",
"dosage" : [ {
"route" : {
"text" : "Oral",
"coding" : [ {
"code" : "C38288",
"display" : "Oral",
"system" : "http://ncithesaurus-stage.nci.nih.gov"
} ]
},
"text" : "At the hour of sleep",
"doseAndRate" : [ {
"doseQuantity" : {
"value" : 1.0
}
} ]
} ],
"effectivePeriod" : {
"start" : "2015-06-24",
"end" : "2015-07-04"
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
MedicationStatement/10951dcd-7b2a-645e-b455-89125db8c249
{
"resourceType" : "MedicationStatement",
"medicationCodeableConcept" : {
"text" : "Ceftriaxone 100 MG/ML",
"coding" : [ {
"code" : "309090",
"display" : "Ceftriaxone 100 MG/ML",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"id" : "10951dcd-7b2a-645e-b455-89125db8c249",
"status" : "active",
"dosage" : [ {
"route" : {
"text" : "Injection",
"coding" : [ {
"code" : "C38276",
"display" : "Injection",
"system" : "http://ncithesaurus-stage.nci.nih.gov"
} ]
},
"doseAndRate" : [ {
"doseQuantity" : {
"value" : 1.0
}
} ]
} ],
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
MedicationStatement/d9f5ff93-557f-e20d-1717-339350fa8573
{
"resourceType" : "MedicationStatement",
"medicationCodeableConcept" : {
"text" : "Clindamycin 300mg",
"coding" : [ {
"code" : "284215",
"display" : "Clindamycin 300mg",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"id" : "d9f5ff93-557f-e20d-1717-339350fa8573",
"status" : "active",
"dosage" : [ {
"route" : {
"text" : "Oral",
"coding" : [ {
"code" : "C38288",
"display" : "Oral",
"system" : "http://ncithesaurus-stage.nci.nih.gov"
} ]
},
"text" : "Oral, three times daily, 1 unit",
"doseAndRate" : [ {
"doseQuantity" : {
"value" : 1.0
}
} ]
} ],
"effectivePeriod" : {
"start" : "2015-06-23",
"end" : "2015-06-30"
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
MedicationStatement/51994ad8-eeb7-5aef-5ff8-0999b809bd08
{
"resourceType" : "MedicationStatement",
"medicationCodeableConcept" : {
"text" : "Torsemide 20mg",
"coding" : [ {
"code" : "198371",
"display" : "Torsemide 20mg",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"id" : "51994ad8-eeb7-5aef-5ff8-0999b809bd08",
"status" : "active",
"dosage" : [ {
"route" : {
"text" : "Oral",
"coding" : [ {
"code" : "C38288",
"display" : "Oral",
"system" : "http://ncithesaurus-stage.nci.nih.gov"
} ]
},
"text" : "Oral, daily, 1 unit",
"doseAndRate" : [ {
"doseQuantity" : {
"value" : 1.0
}
} ]
} ],
"effectivePeriod" : {
"start" : "2015-06-23",
"end" : "2015-06-30"
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Allergies and Intolerances (2 entries)
|
Type
|
Substance
|
Onset
|
Reactions
|
Status
|
|
allergy
|
Ampicillin
|
05/10/1980 12:00AM UTC
|
05/10/1980 12:00AM UTC - Hives - moderate
|
active
|
|
N/A
|
Penicillin G
|
05/10/1980 12:00AM UTC
|
05/10/1980 12:00AM UTC - Hives - moderate
|
active
|
AllergyIntolerance/ce1c9378-522a-8ba6-9bcc-dd57604ed893
{
"patient" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
},
"criticality" : "high",
"clinicalStatus" : {
"coding" : [ {
"code" : "active",
"system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"
} ]
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance" ]
},
"resourceType" : "AllergyIntolerance",
"extension" : [ {
"valueCodeableConcept" : {
"text" : "Allergy to substance (disorder)",
"coding" : [ {
"code" : "419199007",
"display" : "Allergy to substance (disorder)",
"system" : "http://snomed.info/sct"
} ]
},
"url" : "http://onc.org/allergy-observation-value"
}, {
"valueCodeableConcept" : {
"coding" : [ {
"code" : "CONC",
"display" : "CONC",
"system" : "HL7ActClass"
} ]
},
"url" : "http://onc.org/allergy-act-code"
} ],
"recordedDate" : "1980-05-10",
"id" : "ce1c9378-522a-8ba6-9bcc-dd57604ed893",
"code" : {
"text" : "Ampicillin",
"coding" : [ {
"code" : "733",
"display" : "Ampicillin",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"onsetDateTime" : "1980-05-10",
"reaction" : [ {
"manifestation" : [ {
"text" : "Hives",
"coding" : [ {
"code" : "247472004",
"display" : "Hives",
"system" : "http://snomed.info/sct"
} ]
} ],
"onset" : "1980-05-10",
"severity" : "moderate"
} ]
}
AllergyIntolerance/8d92fb85-a24c-9a8d-8e3a-d609c203bbbd
{
"patient" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
},
"criticality" : "unable-to-assess",
"clinicalStatus" : {
"coding" : [ {
"code" : "active",
"system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"
} ]
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance" ]
},
"resourceType" : "AllergyIntolerance",
"extension" : [ {
"valueCodeableConcept" : {
"coding" : [ {
"code" : "CONC",
"display" : "CONC",
"system" : "HL7ActClass"
} ]
},
"url" : "http://onc.org/allergy-act-code"
} ],
"recordedDate" : "1980-05-10",
"id" : "8d92fb85-a24c-9a8d-8e3a-d609c203bbbd",
"code" : {
"text" : "Penicillin G",
"coding" : [ {
"code" : "7980",
"display" : "Penicillin G",
"system" : "http://www.nlm.nih.gov/research/umls/rxnorm"
} ]
},
"onsetDateTime" : "1980-05-10",
"reaction" : [ {
"manifestation" : [ {
"text" : "Hives",
"coding" : [ {
"code" : "247472004",
"display" : "Hives",
"system" : "http://snomed.info/sct"
} ]
} ],
"onset" : "1980-05-10",
"severity" : "moderate"
} ]
}
Consultation Notes (0 entries)
No data for section Consultation Notes
Encounters (0 entries)
|
Date
|
Type
|
Department
|
CareTeam
|
Description
|
|
No records
|
Immunizations (2 entries)
|
Vaccine
|
Date
|
Status
|
Lot
|
Notes
|
|
Tetanus and diphtheria toxoids
|
01/04/2012 12:00AM UTC
|
completed
|
N/A
|
Immunization was not given - Patient rejected immunization
|
|
Influenza, intradermal, quadrivalent, preservative-free
|
06/22/2015 12:00AM UTC
|
not-done
|
No Lot number provided
|
Immunization was not given - Patient rejected immunization
|
Immunization/928d8642-b6f0-9aa4-63bc-0ade244ff102
{
"patient" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization" ]
},
"vaccineCode" : {
"text" : "Tetanus and diphtheria toxoids",
"coding" : [ {
"code" : "106",
"display" : "Tetanus and diphtheria toxoids",
"system" : "http://hl7.org/fhir/sid/cvx"
} ]
},
"resourceType" : "Immunization",
"primarySource" : false,
"status" : "completed",
"id" : "928d8642-b6f0-9aa4-63bc-0ade244ff102",
"lotNumber" : "N/A",
"occurrenceDateTime" : "2012-01-04"
}
Immunization/1a0a96d2-b799-60f0-ff7b-5ed21f916529
{
"patient" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization" ]
},
"vaccineCode" : {
"text" : "Influenza, intradermal, quadrivalent, preservative-free",
"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" : "1a0a96d2-b799-60f0-ff7b-5ed21f916529",
"lotNumber" : "No Lot number provided",
"occurrenceDateTime" : "2015-06-22"
}
Mental Status (0 entries)
No data for section Mental Status
Problems (6 entries)
Active Problems
|
Problem
|
Noted Date
|
Diagnosed Date
|
|
Severe hypothyroidism
|
12/31/2006 12:00AM UTC
|
~
|
|
Chronic rejection of renal transplant
|
12/31/2011 12:00AM UTC
|
~
|
|
Iron deficiency anemia
|
06/22/2015 12:00AM UTC
|
~
|
|
Interstitial pneumonia
|
06/22/2015 12:00AM UTC
|
~
|
|
Essential hypertension
|
05/10/2015 12:00AM UTC
|
~
|
Resolved Problems
|
Problem
|
Noted Date
|
Diagnosed Date
|
Resolved Date
|
|
Overweight
|
12/31/2006 12:00AM UTC
|
~
|
06/01/2007 12:00AM UTC
|
Condition/7740e669-ed03-fd4a-a5c1-94f71e3a3679
{
"onsetDateTime" : "2006-12-31",
"category" : [ {
"coding" : [ {
"system" : "http://terminology.hl7.org/CodeSystem/condition-category",
"code" : "problem-list-item",
"display" : "Problem List Item"
} ]
} ],
"clinicalStatus" : {
"coding" : [ {
"code" : "active",
"system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
} ]
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
},
"resourceType" : "Condition",
"id" : "7740e669-ed03-fd4a-a5c1-94f71e3a3679",
"code" : {
"text" : "Severe hypothyroidism",
"coding" : [ {
"code" : "83986005",
"display" : "Severe hypothyroidism",
"system" : "http://snomed.info/sct"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Condition/a7ff5e25-3fbb-eb1b-7ff1-80be1cfcf2a3
{
"onsetDateTime" : "2011-12-31",
"category" : [ {
"coding" : [ {
"system" : "http://terminology.hl7.org/CodeSystem/condition-category",
"code" : "problem-list-item",
"display" : "Problem List Item"
} ]
} ],
"clinicalStatus" : {
"coding" : [ {
"code" : "active",
"system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
} ]
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
},
"resourceType" : "Condition",
"id" : "a7ff5e25-3fbb-eb1b-7ff1-80be1cfcf2a3",
"code" : {
"text" : "Chronic rejection of renal transplant",
"coding" : [ {
"code" : "236578006",
"display" : "Chronic rejection of renal transplant",
"system" : "http://snomed.info/sct"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Condition/646bbecc-42ea-b60b-3f73-85b07ccd3f57
{
"onsetDateTime" : "2015-06-22",
"category" : [ {
"coding" : [ {
"system" : "http://terminology.hl7.org/CodeSystem/condition-category",
"code" : "problem-list-item",
"display" : "Problem List Item"
} ]
} ],
"clinicalStatus" : {
"coding" : [ {
"code" : "active",
"system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
} ]
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
},
"resourceType" : "Condition",
"id" : "646bbecc-42ea-b60b-3f73-85b07ccd3f57",
"code" : {
"text" : "Iron deficiency anemia",
"coding" : [ {
"code" : "87522002",
"display" : "Iron deficiency anemia",
"system" : "http://snomed.info/sct"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Condition/96ded1d1-7fe4-e744-3c79-e8c7366d6075
{
"onsetDateTime" : "2015-06-22",
"category" : [ {
"coding" : [ {
"system" : "http://terminology.hl7.org/CodeSystem/condition-category",
"code" : "problem-list-item",
"display" : "Problem List Item"
} ]
} ],
"clinicalStatus" : {
"coding" : [ {
"code" : "active",
"system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
} ]
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
},
"resourceType" : "Condition",
"id" : "96ded1d1-7fe4-e744-3c79-e8c7366d6075",
"code" : {
"text" : "Interstitial pneumonia",
"coding" : [ {
"code" : "64667001",
"display" : "Interstitial pneumonia",
"system" : "http://snomed.info/sct"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Condition/79624cdf-12eb-942f-034e-2d084de3b67f
{
"category" : [ {
"coding" : [ {
"system" : "http://terminology.hl7.org/CodeSystem/condition-category",
"code" : "problem-list-item",
"display" : "Problem List Item"
} ]
} ],
"clinicalStatus" : {
"coding" : [ {
"code" : "resolved",
"system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
} ]
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
},
"resourceType" : "Condition",
"id" : "79624cdf-12eb-942f-034e-2d084de3b67f",
"code" : {
"text" : "Overweight",
"coding" : [ {
"code" : "238131007",
"display" : "Overweight",
"system" : "http://snomed.info/sct"
} ]
},
"onsetDateTime" : "2006-12-31",
"abatementDateTime" : "2007-06-01",
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Condition/51c647e9-fe88-fc17-9c59-7b9e80aa144f
{
"onsetDateTime" : "2015-05-10",
"category" : [ {
"coding" : [ {
"system" : "http://terminology.hl7.org/CodeSystem/condition-category",
"code" : "problem-list-item",
"display" : "Problem List Item"
} ]
} ],
"clinicalStatus" : {
"coding" : [ {
"code" : "active",
"system" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
} ]
},
"meta" : {
"profile" : [ "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns" ]
},
"resourceType" : "Condition",
"id" : "51c647e9-fe88-fc17-9c59-7b9e80aa144f",
"code" : {
"text" : "Essential hypertension",
"coding" : [ {
"code" : "59621000",
"display" : "Essential hypertension",
"system" : "http://snomed.info/sct"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Goals (0 entries)
a. Need to gain more energy to do regular activities.
b. Negotiated Goal to keep Body Temperature at 98-99 degrees Fahrenheit with regular
monitoring
Functional Status (0 entries)
No data for section Functional Status
Discharge Summary (0 entries)
No data for section Discharge Summary
Progress Notes (1 entries)
Henry Seven - 06/22/2015 12:00AM UTC
Ms Rebecca Larson got admitted due to developing high fever and since has shown considerable
improvement and can be discharged shortly.
Observation/4469eb5f-38dd-114c-049e-5fd2912af18f
{
"id" : "4469eb5f-38dd-114c-049e-5fd2912af18f",
"code" : {
"coding" : [ {
"code" : "11506-3",
"system" : "http://loinc.org",
"display" : "Progress Note"
} ]
},
"note" : [ {
"text" : "Ms Rebecca Larson got admitted due to developing high fever and since has shown considerable\nimprovement and can be discharged shortly."
} ],
"effectiveDateTime" : "2015-06-22",
"performer" : [ {
"reference" : "urn:uuid:ada42cdd-ed1d-da17-4de7-267d7a3ffef6"
} ],
"status" : "final",
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
},
"resourceType" : "Observation"
}
Medical Equipment (1 entries)
|
ID
|
Assigning Auth
|
Code
|
Date
|
|
(01)00643169007222(17)160128(21)BLC200461H
|
FDA
|
Cardiac resynchronization therapy implantable pacemaker
|
10/05/2011 12:00AM UTC
|
Procedure/1ab0b7c4-55ac-127a-ce21-c25338f1e377
{
"focalDevice" : [ {
"manipulated" : {
"reference" : "urn:uuid:96367297-2eac-9b27-bf43-6b5071a1b82f"
},
"action" : {
"text" : "Cardiac resynchronization therapy implantable pacemaker",
"coding" : [ {
"code" : "704708004",
"display" : "Cardiac resynchronization therapy implantable pacemaker",
"system" : "http://snomed.info/sct"
} ]
}
} ],
"resourceType" : "Procedure",
"extension" : [ {
"valueCode" : "procedure",
"url" : "rim-class"
} ],
"status" : "completed",
"id" : "1ab0b7c4-55ac-127a-ce21-c25338f1e377",
"performedDateTime" : "2011-10-05T00:00:00Z",
"code" : {
"text" : "Introduction of cardiac pacemaker system via vein",
"coding" : [ {
"code" : "175135009",
"display" : "Introduction of cardiac pacemaker system via vein",
"system" : "http://snomed.info/sct"
} ]
},
"bodySite" : [ {
"text" : "Structure of subclavian vein",
"coding" : [ {
"code" : "9454009",
"display" : "Structure of subclavian vein",
"system" : "http://snomed.info/sct"
} ]
} ],
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Discharge Instructions (0 entries)
a. Diet: Diabetic low salt diet
b. Medications: Take prescribed medications as advised.
c. Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up
with Outpatient facility for Immunosuppression treatment.
d. For Fever of > 101.5 F, or onset of chest pain/breathlessness contact Emergency.
Procedures (3 entries)
|
Procedures
|
Date
|
Status
|
|
Bronchoscopy
|
06/22/2015 12:00AM UTC
|
completed
|
|
Chest X-Ray, PA and Lateral Views
|
06/22/2015 12:00AM UTC
|
completed
|
|
Introduction of cardiac pacemaker system via vein
|
10/05/2011 12:00AM UTC
|
completed
|
Procedure/1ab0b7c4-55ac-127a-ce21-c25338f1e377
{
"focalDevice" : [ {
"manipulated" : {
"reference" : "urn:uuid:96367297-2eac-9b27-bf43-6b5071a1b82f"
},
"action" : {
"text" : "Cardiac resynchronization therapy implantable pacemaker",
"coding" : [ {
"code" : "704708004",
"display" : "Cardiac resynchronization therapy implantable pacemaker",
"system" : "http://snomed.info/sct"
} ]
}
} ],
"resourceType" : "Procedure",
"extension" : [ {
"valueCode" : "procedure",
"url" : "rim-class"
} ],
"status" : "completed",
"id" : "1ab0b7c4-55ac-127a-ce21-c25338f1e377",
"performedDateTime" : "2011-10-05T00:00:00Z",
"code" : {
"text" : "Introduction of cardiac pacemaker system via vein",
"coding" : [ {
"code" : "175135009",
"display" : "Introduction of cardiac pacemaker system via vein",
"system" : "http://snomed.info/sct"
} ]
},
"bodySite" : [ {
"text" : "Structure of subclavian vein",
"coding" : [ {
"code" : "9454009",
"display" : "Structure of subclavian vein",
"system" : "http://snomed.info/sct"
} ]
} ],
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Procedure/8985bf1f-fba5-a0f5-24f0-35afad2854fa
{
"performedDateTime" : "2015-06-22",
"resourceType" : "Procedure",
"extension" : [ {
"valueCode" : "act",
"url" : "rim-class"
} ],
"status" : "completed",
"id" : "8985bf1f-fba5-a0f5-24f0-35afad2854fa",
"code" : {
"text" : "Bronchoscopy",
"coding" : [ {
"code" : "10847001",
"display" : "Bronchoscopy",
"system" : "http://snomed.info/sct"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
Procedure/ae257d95-22f4-a228-cb43-efb5a0e0c1ed
{
"performedDateTime" : "2015-06-22",
"resourceType" : "Procedure",
"extension" : [ {
"valueCode" : "act",
"url" : "rim-class"
} ],
"status" : "completed",
"id" : "ae257d95-22f4-a228-cb43-efb5a0e0c1ed",
"code" : {
"text" : "Chest X-Ray, PA and Lateral Views",
"coding" : [ {
"code" : "168731009",
"display" : "Chest X-Ray, PA and Lateral Views",
"system" : "http://snomed.info/sct"
} ]
},
"subject" : {
"reference" : "urn:uuid:9f8231b9-aa93-0d4b-04a7-44e76a7a0a5b"
}
}
History And Physical Notes (0 entries)
No data for section History And Physical Notes
Social History (2 entries)
|
Element
|
Date
|
Value
|
|
Tobacco smoking status NHIS
|
06/22/2015 12:00AM UTC
|
Current every day smoker
|
|
Sex Assigned At Birth
|
~
|
Female
|
Observation/86c0580c-ee2e-70be-2664-ac9d50c89aae
{
"category" : [ {
"coding" : [ {
"code" : "social-history",
"display" : "Social History",
"system" : "http://terminology.hl7.org/CodeSystem/observation-category"
} ]
} ],
"valueCodeableConcept" : {
"text" : "Female",
"coding" : [ {
"code" : "F",
"display" : "Female",
"system" : "urn:oid:2.16.840.1.113883.5.1"
} ]
},
"resourceType" : "Observation",
"status" : "final",
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Observation/98f0cb44-e7cc-135f-2005-3489c60656e3
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"valueCodeableConcept" : {
"text" : "Current every day smoker",
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Assesments (0 entries)
The patient was found to have Anemia and Dr Seven and his staff diagnosed
the condition and treated Ms Rebecca for Anemia during the 2 day stay at
Community Health Hospitals. Ms Rebecca 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
Health Concerns (0 entries)
a. Chronic Sickness exhibited by patient
b. HealthCare Concerns refer to underlying clinical facts
i. Documented HyperTension problem
ii. Documented HypoThyroidism problem
iii. Watch Weight of patient
iv. Documented Anemia problem
Hospital Course (0 entries)
Ms. Rebecca Larson 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.
Laboratory Notes (1 entries)
Henry Seven - 06/22/2015 12:00AM UTC
Ms Rebecca Larson was tested for the Urinanalysis macro panel and CBC and the results have been
found to be normal.
Observation/2cf6c804-a0cb-7d0e-ffde-2f264cee24e0
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Results (2 entries)
Urinanalysis macro (dipstick) panel, No performer ID, No Lab, No Lab Address
|
Code
|
Value
|
Date
|
|
Color of urine
|
YELLOW
|
06/22/2015 12:00AM UTC
|
|
Appearance of urine
|
CLEAR
|
06/22/2015 12:00AM UTC
|
|
Specific gravity of urine by test strip
|
1.015 1
|
06/22/2015 12:00AM UTC
|
|
pH of Urine by Test strip
|
5.0 [pH]
|
06/22/2015 12:00AM UTC
|
|
Glucose [Mass/volume] in urine by test strip
|
50 mg/dL
|
06/22/2015 12:00AM UTC
|
|
Ketones [Mass/Volume] in urine by test strip
|
Negative
|
06/22/2015 12:00AM UTC
|
|
Protein [Mass/Volume] in urine by test strip
|
100 mg/dL
|
06/22/2015 12:00AM UTC
|
CBC, No performer ID, No Lab, No Lab Address
|
Code
|
Value
|
Date
|
|
HGB
|
10.2 g/dL
|
06/22/2015 12:00AM UTC
|
|
WBC
|
12.3 10*3/uL
|
06/22/2015 12:00AM UTC
|
|
PLT
|
123 10*3/ul
|
06/22/2015 12:00AM UTC
|
|
Everolimus Blood
|
10 ng/mL
|
06/22/2015 12:00AM UTC
|
Observation/d584d35d-72a6-c23c-bbb4-52fd3527c1e4
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Observation/b326c75f-a458-370b-51d9-217751f7c66b
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Plan of treatment (1 entries)
i. Schedule an appointment with Dr Seven after 1 week for Follow up with
Outpatient facility for Immunosuppressive therapy.
Observation/6af0f406-49fb-6b27-5566-fe8e85e1c0b8
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Procedures Notes (1 entries)
Henry Seven - 06/22/2015 12:00AM UTC
Dr Seven examined Ms Rebecca Larson and found that the pacemaker is operating properly and the
breathlessness is due to high fever and anxiety.
Observation/9167b038-66a0-ba39-0bac-de91bf0c9576
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Payers (0 entries)
No data for section Payers
Vital Signs (9 entries)
|
Vital sign
|
Date
|
Value and units
|
|
Blood Pressure Systolic
|
06/22/2015 3:08PM UTC
|
145 mm[Hg]
|
|
Blood Pressure Diastolic
|
06/22/2015 3:08PM UTC
|
88 mm[Hg]
|
|
Heart Rate
|
06/22/2015 3:10PM UTC
|
80 /min
|
|
Body Temperature
|
06/22/2015 3:15PM UTC
|
38 Cel
|
|
Respiratory Rate
|
06/22/2015 3:15PM UTC
|
18 /min
|
|
O2 % BldC Oximetry
|
06/22/2015 3:12PM UTC
|
95 %
|
|
Inhaled Oxygen Concentration
|
06/22/2015 3:12PM UTC
|
36 %
|
|
Weight
|
06/22/2015 3:05PM UTC
|
88 kg
|
|
Height
|
06/22/2015 3:05PM UTC
|
177 cm
|
|
BMI
|
~
|
~
|
|
Head Occipital Circumference
|
~
|
~
|
Observation/15b8f969-61e4-2fc0-cb69-15681e436b91
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Observation/23314b89-9e8f-585a-3657-55172c993cff
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Observation/53736391-0171-91b8-44be-e65e4f71432d
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Observation/e4d0d986-62db-1dac-7352-2a60f367589b
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Observation/0a8bdbbc-9522-b556-b81f-b0445f663d69
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Observation/2fbe1166-7cca-53e8-0012-f4f49cb480b5
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Observation/d3c1d944-0c3b-923d-bf73-edd2c76e5864
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