Patient Summary (HL7 CCD)

Document Effective: 07/21/2017 21:15

Encounter Dates:07/19/2017 through 07/19/2017

Contents
Patient Demographics
Care Team
Provider Organization
Vital Signs
Allergies
Procedures
History of Immunizations
Problems
Results
Active Medications
Medications Administered During Visit
Encounters
Social History
Patient Decision Aids
Discharge Instructions
Chief Complaint and Reason For Visit
Function Status
Plan of Care
Referral/Transition of Care

Patient Demographics [back to top]

NameEVA H BRISTOW
Address73 OLD COWAN SCHOOL
ROAD
ALBANY, KY 42602
Primary Home6063875884
Date of Birth11/09/1946
SexF
Race
EthnicityNot Hispanic or Latino
Language SpokenEnglish

Care Team [back to top]

NameAddressPhoneRole
ALLISON SMITH CHERRY850 HAIL KNOB RD STE A
SOMERSET, KY 42503
6066784288 (Work Place)
Attending Physician
ALLISON SMITH CHERRY850 HAIL KNOB RD STE A
SOMERSET, KY 42503
6066784288 (Work Place)
Rounding (Secondary) Physician

Provider Organization [back to top]

NameTHE MEDICAL CENTER AT ALBANY
Address723 BURKESVILLE RD
ALBANY, KY 426021654
Work Place6063876421

Vital Signs [back to top]

Unknown or Not Available.

Allergies [back to top]

Allergy Code Allergy Type Reaction Status
CODEINE 2670 Drug allergy Active

Procedures [back to top]

Unknown or Not Available.

History of Immunizations [back to top]

Unknown or Not Available.

Problems [back to top]

Problem Code Start Date Resolved Date Status
Sepsis 91302008 Active

Results [back to top]

HEMOGLOBIN A1C - Collect Date/Time: 07/19/2017 15:50
Test Name Code Test Result Test Units Test Ref Range
HEMOGLOBIN A1C 4548-4 7.90 % L=4.40 H=6.40

CBC - Collect Date/Time: 07/19/2017 15:50
Test Name Code Test Result Test Units Test Ref Range
WBC 6690-2 11.30 th/ul L=4.80 H=10.80
RBC 789-8 3.94 mil/ul L=4.20 H=5.40
HEMOGLOBIN 718-7 11.5 g/dl L=12.0 H=16.0
HEMATOCRIT 4544-3 36.0 % L=37.0 H=47.0
MCV 787-2 91 fl L=81 H=99
MCH 785-6 29 pg L=27 H=31
MCHC 786-4 32 g/dl L=33 H=37
RDW 788-0 14.8 % L=11.5 H=14.5
PLATELET CT 777-3 283 th/ul L=130 H=400
MPV 32623-1 8.1 fl L=7.4 H=10.4
NE% 770-8 56.1 % L=43.0 H=65.0
LYMPH % 736-9 30.4 % L=20.5 H=51.1
MONO % 5905-5 6.7 % L=1.7 H=9.3
EO% 713-8 6.2 % L=0.9 H=2.9
BA% 706-2 0.6 % L=0.2 H=1.0
NE# 751-8 6.3 th/ul L=2.2 H=4.8
LYMPH # 731-0 3.4 th/ul L=1.2 H=3.4
MONO # 742-7 0.8 th/ul L=0.1 H=0.5
EO# 711-2 0.7 th/ul L=0.0 H=0.2
BA# 704-7 0.1 th/ul L=0.0 H=0.1
Manual Diff 24318-8 Not Indicated N/A

BASIC METABOLIC PANEL - Collect Date/Time: 07/19/2017 15:50
Test Name Code Test Result Test Units Test Ref Range
SODIUM 2951-2 138 mmol/L L=137 H=145
POTASSIUM 2823-3 4.0 mmol/L L=3.6 H=5.0
CHLORIDE 2075-0 100 mmol/L L=98 H=107
tCO2 2028-9 24.0 mmol/L L=22.0 H=29.0
GLUCOSE 2345-7 149 mg/dl L=70 H=99
BUN 3094-0 23 mg/dl L=7 H=20
CREATININE 2160-0 1.0 mg/dl L=0.5 H=1.1
CALCIUM 17861-6 9.9 mg/dl L=8.4 H=10.2
AGE 30525-0 70 YRS
EST GFR NONAA 48642-3 79
RACE WHITE N/A

Active Medications [back to top]

Unknown or Not Available.

Medications Administered During Visit [back to top]

Unknown or Not Available.

Encounters [back to top]

Unknown or Not Available.

Social History [back to top]

Smoking Status Code Start Date End Date
Never smoker 266919005

Patient Decision Aids [back to top]

Unknown or Not Available.

Discharge Instructions [back to top]


You were admitted to THE MEDICAL CENTER AT ALBANY on 07/19/2017 15:36

You had the following tests done:

  • BASIC METABOLIC PANEL
  • CBC
  • HEMOGLOBIN A1C

You were discharged from THE MEDICAL CENTER AT ALBANY on 07/19/2017 15:36

Should you have any questions prior to discharge, please contact a member of your healthcare team. If you have left the hospital and have any questions, please contact your primary care physician.

Chief Complaint and Reason For Visit [back to top]

Chief Complaint Date of Onset
E1165 E782 I10

Function Status [back to top]

Unknown or Not Available.

Plan of Care [back to top]

Unknown or Not Available.

Referral/Transition of Care [back to top]

Unknown or Not Available.