| Patient | John Doe, Sr | ||
| Date of birth | June 18, 1990 | Sex | Male |
| Race | Asian Indian | Ethnicity | Not Hispanic or Latino |
| Contact info | Primary Home: 234 Minor Street 123 Main Street & Road Philadelphia, PA 19136, USA Tel: (323)555-1111 | Patient IDs | 1001 2.16.840.1.113883.19.5.99999.2 123-45-6789 2.16.840.1.113883.4.1 |
| Document Id | 201806201202.: 2.16.840.1.113883.19.5.99999.1 |
| Document Created | June 20, 2018, 12:02:50 -0900 |
| Performer | Get Well Clinic | ||
| Author | Abbey Duck, MD |
| Contact info | 234 Main Street Los Angeles, CA 90024, USA Tel: (323)238-4727 |
| Signed | Peter Peterson, JD |
| Contact info | 92 Water Street Los Angeles, CA 90077, USA Tel: (818)267-8243 |
| Information recipient | John Doe, Sr |
| Legal authenticator | Abbey Duck, MD signed at June 20, 2018, 12:02:50 -0900 |
| Contact info | 234 Main Street Los Angeles, CA 90024, USA Tel: (323)238-4727 |
| Document maintained by | Saint Joseph |
| Contact info | 99 Water Street Culver City, CA 90230, USA Tel: (310)555-2222 |
| Type | Date | Substance | Reaction | Code | Status |
|---|---|---|---|---|---|
| Allergy | 09/28/2016 | PEANUT | head & arms ache | 36987155001 (NDC) | Active |
| Allergy | 11/29/2016 | ASPIRIN | 1191 (RXNORM) | Active | |
| Adverse Reaction | Approximate Onset Date: 2013 | Headaches | Current | ||
| Adverse Reaction | 05/14/2012 | Stress | headaches, gastritis | 73595000 (SNOMED) | Current |
| Alert | 12/21/2012 | Headaches | pain | 2411 (NDC) | Current |
| Alert | 03/29/2014 | Stress | headaches, nausea | Historical |
| Type | Date | Description | Code | Status |
|---|---|---|---|---|
| Ambulatory Status | Onset Date: 03/25/2014 | New York Heart Association Classification - Class IV | 422293003 (SNOMED) | Resolved |
| Assessment for Heart Failure | Onset Date: 12/30/2016, 07:51 AM | Fy sup(a) Ag RBC Ql | 1027-2 (LOINC) | Active |
| Functional Status Result | Onset Date: 02/10/2017 | % area reduction | 397441001 (SNOMED) | Active |
| Functional Status Result | Onset Date: 02/10/2017 | Norpropoxyph SerPl-mCnc | 10341-6 (LOINC) | Active |
| Social History | Description | Effective Date | Code |
|---|---|---|---|
| Alcohol | Alcohol consumption | 03/01/2012 to 01/01/2015 | 123456789 (SNOMED) |
| Smoking | Current every day smoker | 10/30/2016 | 449868002 (SNOMED) |
| Smoking | Smokeless Tobacco | 06/10/2018 | 95269005 (SNOMED) |
| Marital Status | Never Married | ||
| Religion | Christian | ||
| Ethnicity | Not Hispanic or Latino | 2186-5 (SNOMED) | |
| Primary Language | English | ||
| Employment | Full-time | ||
| Nationality | Declines to answer | ||
| Citizenship | ARMENIA | ||
| Birthplace | Los Angeles | ||
| Time of Birth | 04:23 AM | ||
| Birth Order | 3 | ||
| Highest Degree | Doctorate | ||
| Indian Health Services (IHS) Tribe | California Tribe | ||
| Race | White, Native Hawaiian / Other Pacific Islander, Asian Indian | ||
| Usual Industry | Legal Services | 7270 (Census Industry Code) | |
| Usual Occupation | Civil Engineer | 172051 (Census Occupation Code) |
| May 13,2016 | Jul 18,2016 | Jul 20,2016 | |
|---|---|---|---|
| Temp | 98.6 F | 98.6 F | 98.6 F |
| Weight | 134 lb | 122 lb | 135 lb |
| Height | 63 in | 63 in | 63 in |
| Blood Pressure | 110/70 mmHg (Right Arm) | 130/90 mmHg (Right Arm) | 115/80 mmHg (Right Arm) |
| Pulse | 23 | 20 | |
| BMI | 23.73 | 21.61 | 23.91 |
| Nov 30,2016 | Feb 06,2017 | Feb 10,2017 | |
|---|---|---|---|
| Temp | 98.6 F | 98.6 F | |
| Weight | 250 lb | ||
| Height | 63 in | 63 in | 63 in |
| Blood Pressure | 189/100 mmHg (Left Arm) | 110/70 mmHg (Right Arm) | 110/90 mmHg (Left Arm) |
| Pulse | 34 | ||
| BMI | 44.28 |
| Type | Date | Description | Code | Status |
|---|---|---|---|---|
| Diagnosis | Onset: 06/04/2018 | Cyclical vomiting, not intractable | G43.A0 (ICD-10) | Active |
| Problem | Onset: 09/25/2016 Resolved: 06/10/2018 |
Alzheimer's disease | 331.0 (ICD-10) | Inactive |
| Problem | 06/05/2018 | Low back pain | Active |
| Date | Medication | Dosage | SIG | Code | Status |
|---|---|---|---|---|---|
| 01/24/2017 | LASIX | [20 mg] TABLET | As needed | 00039006710 (NDC) | Inactive |
| 01/24/2017 | ACETAMINOPHEN | [325 mg] TABLET | Four times a day | 00615059131 (NDC) | Active |
| 06/16/2018 | ASPIRIN | [325 ng] TABLET | by mouth once daily | 49483001100 (NDC) | Ordered |
| Date | Progress Note |
|---|---|
| 09/23/2016 | This CDoc presents: John Doe 123 Main Street & Road Philadelphia, PA 19136 (323) 555-1111 Patient is a 18 year old Male with a history of + 8/4/2016 M8500/3 Infiltrating duct carcinoma + 8/18/2016 G43.A0 Cyclical vomiting, not intractable + 9/19/2016 176 Kaposi's sarcoma + 9/20/2016 005.1 Botulism The patient is under the care of: Abbey S. Duck 20140 Scholar Drive, Suite 316 Martinsburg, WV 25401 (301) 555-1212 |
| Date | Chief Complaint |
|---|---|
| 09/23/2016 | This CDoc presents: John Doe 123 Main Street & Road Philadelphia, PA 19136 (323) 555-1111 Patient is a 18 year old Male with a history of + 8/4/2016 M8500/3 Infiltrating duct carcinoma + 8/18/2016 G43.A0 Cyclical vomiting, not intractable + 9/19/2016 176 Kaposi's sarcoma + 9/20/2016 005.1 Botulism The patient is under the care of: Abbey S. Duck 20140 Scholar Drive, Suite 316 Martinsburg, WV 25401 (301) 555-1212 |
| 06/28/2017 | This CDoc presents: John Doe 123 Main Street & Road Philadelphia, PA 19136 (323) 555-1111 Patient is a 18 year old Male with a history of + 8/4/2016 M8500/3 Infiltrating duct carcinoma + 8/18/2016 G43.A0 Cyclical vomiting, not intractable + 9/19/2016 176 Kaposi's sarcoma + 9/20/2016 005.1 Botulism The patient is under the care of: Abbey S. Duck 20140 Scholar Drive, Suite 316 Martinsburg, WV 25401 (301) 555-1212 |
| Past Medical History |
|---|
| 01/04/2015 12:33 am [ASD] Patient reported Medical History: Arteriosclerosis, Blood disorders, Hypertension, Kidney disease Illnesses and Conditions: Allergic disorders [2009] Personal Habits: None reported Exercise Patterns: Exercise - never Sleep Patterns: Sleep: more than 12 hours / day Allergic Reaction to Medications: None reported Allergic Reaction to Foods: Beets; Nuts Allergic Reaction to Environment: Fiber Allergic Reaction to Bites and Stings: Honey bees Other Allergic Reactions: tide detergent Patient Annotations: nothing here Patient reported Medical History: Alcoholism, Allergic disorders |
| Date | Assessment and Plan |
|---|---|
| 08/02/2016 | dg dfgdfgdg |
| 06/28/2017 | Plan of Treatment: After completing an initial examination and evaluation of Mr. Doe, I have selected a plan of treatment that should return this patient to a pre-injury status and minimize the possibility of future residuals. The patient will be seen 2 times per week for a period of 6 weeks. The patient's treatment program will include a Gonstead adjustive technique at C3 with a normal degree of movement. Therapy will include traction on the lumbar region to reduce pain. |
| Date | General Status |
|---|---|
| 08/02/2016 | sdfsdf sdf sdf s |
| 06/28/2017 | Prognosis is good. |
| Date | Description | Result | Units | Abnormal | Normal Range | Code |
|---|---|---|---|---|---|---|
| 11/15/2016 | Rh [Type] in Blood | 23 | mg | X | 1 to 2 | 10331-7 (LOINC) |
| 09/22/2015 | PSA | 8 | mg | 1234567 (LOINC) | ||
| 06/08/2018 | PSA | 32 | mg | 234234 (SNOMED) |
| Date | Immunizations | Route | Site | Code |
|---|---|---|---|---|
| 11/05/1992 | DTaP-Hib-IPV | 120 (CVX) | ||
| 05/28/2018 | HPV, bivalent | Intradermal | Left Arm | 118 (CVX) |
| 11/26/1994 | Pneumo (PPV23) | 33 (CVX) | ||
| 05/17/1992 | Tdap | Intramuscular | Left Arm | 115 (CVX) |
| 11/26/2016 | Varicella | 21 (CVX) |
| Type | Date | Description | Status |
|---|---|---|---|
| Resuscitation Status | 01/23/2015 | Supported by Healthcase Will | Do not resuscitate |
| Intubation Status | 11/07/2011 | Verified with Family Only | notes for & intubation status |
| IV Fluid and Support Status | 11/07/2011 | Supported by Healthcase Will | notes for iv fluid & support status |
| CPR Status | 11/07/2011 | Verified with Family Only | notes for cpr & status |
| Antibiotic Status | 11/07/2011 | Current and Verified | notes for & anitbiotic status |
| Life Support Status | 11/07/2011 | Verified with Family Only | notes for life & support status |
| Tube Feeding Status | 11/07/2011 | Current and Verified | notes for tube & feeding status |
| Other Status | 11/07/2011 | Current and Verified | notes for & other status |
| Type | Date | Device | Quantity | Serial# | Instructions | Status |
|---|---|---|---|---|---|---|
| Implantable Device | 11/26/2013 | Breast Implant | 1 | 243211414 | asd asd asd | Completed |
| Device | 11/26/2013 | BONEFAST | 1 | On Hold | ||
| Implantable Device | 08/02/2016 | Breast Implant | 1 | Active |
| Date | Description | Body Site | Code | Status |
|---|---|---|---|---|
| 02/13/2012 | Standard chest X-ray | 168731009 (SNOMED) | ordered | |
| 03/21/2014 | Obesity | Head and neck arterial embolus | 414916001 (SNOMED) | performed |
| 12/30/2014 | Congestive heart failure | 42343007 (SNOMED) | ||
| 01/24/2015 | Colonic polypectomy | Imaging of abdomen (Snomed CT 441987005) | 274025005 (SNOMED) | |
| 09/23/2016 | Collection of blood specimen for laboratory | 82078001 (SNOMED) | ||
| 11/27/2016 | % activity | 258745004 (SNOMED) |
| Type | Date | Code |
|---|---|---|
| ED Admission date ED Discharge date |
05/21/2018 05/27/2018 |
32485007 (SNOMED) |
| INP Admission date INP Discharge date |
06/03/2018 06/09/2018 |
394656005 (SNOMED) |
| Date | Plan | Instructions | Type | Code |
|---|---|---|---|---|
| 04/29/2015 | Chest X-Ray | Scheduled Imaging | 198942000 (SNOMED) | |
| 05/01/2015 | Colonoscopy | Scheduled Procedure | 45378 (SNOMED) | |
| 05/01/2015 | HGB | asdasdasd | Scheduled Lab | 30313-1 (NDC) |
| 09/22/2016 | , , - Donec fringilla tempus lacus. Aenean at neque non est fringilla volutpat. V | Donec fringilla tempus lacus. Aenean at neque non est fringilla volutpat. Vivamus libero velit, rutrum quis, aliquet et, porta nec, dui. Maecenas venenatis, ipsum a laoreet ultrices, purus tellus iaculis eros, a ultrices tortor ligula et wisi. Morbi tincidunt odio et erat. Phasellus quis mi accumsan augue vestibulum euismod. Donec lorem. Sed sagittis erat at est. In pede massa, suscipit eu, rutrum vel, fermentum ut, dolor. Curabitur vel est congue nunc convallis lobortis. | Referral to other provider | |
| Thu 07/21/2016 at 11:00 am | Abbey Duck MD, 20140 Scholar Drive, Suite 316, Martinsburg WV | Future appointment |
| Type | Name | Address | Phone |
|---|---|---|---|
| Attending Provider | Abbey S. Duck MD | 20140 Scholar Drive, Suite 316, Martinsburg, WV 25401 | (304) 555-1212 |
| Referring Provider | Nicholas Radon | , , | |
| Last Ordering Provider | Ben Kildare MD | 234 Seaway Street, Miami, FL 33111 | (800) 555-1199 |
| Last Supervising Provider | Adams Anderson PhD | 222 Manin Street, Orlando, FL 32821 | (313) 334-3599 |
| Last Rendering Provider | Abbey S. Duck MD | 20140 Scholar Drive, Suite 316, Martinsburg, WV 25401 | (304) 555-1212 |
| Primary Care Provider | Mickey M. Mouse MD | 34 Disney Lane, Liverpool, NY 13090 | (315) 555-3434 |
| Primary Hospital - Preferred | Adams Academy Hospital | 335 Main Street, Los Angeles, CA 90024 | (310) 283-4729 |
| Second Hospital | City Hospital | 99 City Street, Martinsburg, WV 25401 | (304) 273-4826 |
| Date | Instructions | Type | Code |
|---|---|---|---|
| 04/30/2015 | test test test | Clinical Instructions | 311401005 (SNOMED) |
| Date | Instructions |
|---|---|
| 09/22/2016 | Abbey S. Duck, MD 20140 Scholar Drive, Suite 316 Los Angeles, CA 90024 (310) 555-0038 FAX (310) 555-8490 www.legacypress.com NAME: John Doe DOB: 06/18/1998 DATE: September 22, 2016 DIAGNOSIS: * 8/4/2016 M8500/3 Infiltrating duct carcinoma * 8/18/2016 G43.A0 Cyclical vomiting, not intractable * 9/17/2016 * 9/17/2016 * 9/19/2016 176 Kaposi's sarcoma * 9/20/2016 005.1 Botulism ALLERGIES: * CODEINE * SULFUR * ASPIRIN MEDICATIONS: * ALLOPURINOL [300 mg] TABLET, As needed * CLARITHROMYCIN [250 mg] TABLET, 1 tablet per day by mouth * LISINOPRIL, once daily We appreciate your choosing us for your urgent care needs. These are the instructions your Physician/PA has given you. Please read them carefully. We are here to serve you. The examination and treatment you have received in this clinic has been done on an urgent care basis. In most cases it is important that you be rechecked again. If you had any x-rays or special test they will be reviewed within 24-48 hours. You will be notified if a change in your treatment program is indicated. Please follow the instructions provided below. |