Patient Summary (HL7 CCD)

Document Effective: 10/29/2015 08:01

Encounter Dates:03/19/2015 through 03/23/2015

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
MICHAEL MD CUMMINGSTWING LAKES MEDICAL PLAZA
127 FOOTHILLS AVE
ALBANY, KY 42602
6063876627 (Work Place)
Attending Physician

Provider Organization [back to top]

NameCLINTON COUNTY HOSPITAL
Address723 BURKESVILLE RD
ALBANY, KY 426021654
Work Place6063876421

Vital Signs [back to top]

Vital Sign Value Unit Date/Time Recent/Initial?
BP Systolic 129 mmHg 03/19/2015 16:56 Initial VS
BP Diastolic 66 mmHg 03/19/2015 16:56 Initial VS
Respiratory Rate 22 bpm 03/19/2015 16:56 Initial VS
Heart Rate 72 bpm 03/19/2015 16:56 Initial VS
O2 % BldC Oximetry 96 % 03/19/2015 16:56 Initial VS
Body Temperature 98.1 degrees 03/19/2015 16:56 Initial VS
BP Systolic 112 mmHg 03/23/2015 15:22 Most Recent VS
BP Diastolic 70 mmHg 03/23/2015 15:22 Most Recent VS
Respiratory Rate 20 bpm 03/23/2015 15:22 Most Recent VS
Heart Rate 96 bpm 03/23/2015 15:22 Most Recent VS
O2 % BldC Oximetry 96 % 03/23/2015 15:22 Most Recent VS
Body Temperature 97.7 degrees 03/23/2015 15:22 Most Recent VS

Allergies [back to top]

Allergy Code Allergy Type Reaction Status
CODEINE 2670 Drug allergy Active

Procedures [back to top]

Procedure Code Procedure Type Date
INJECT ANTIBIOTIC 9921 ICD-9 CM, Volume 3 03/19/2015
INJECT STEROID 9923 ICD-9 CM, Volume 3 03/19/2015
INJECT ANTIBIOTIC 9921 ICD-9 CM, Volume 3 03/20/2015
INJECT STEROID 9923 ICD-9 CM, Volume 3 03/20/2015
INJECT ANTIBIOTIC 9921 ICD-9 CM, Volume 3 03/21/2015
INJECT STEROID 9923 ICD-9 CM, Volume 3 03/21/2015
INJECT ANTIBIOTIC 9921 ICD-9 CM, Volume 3 03/22/2015
INJECT STEROID 9923 ICD-9 CM, Volume 3 03/23/2015

History of Immunizations [back to top]

Unknown or Not Available.

Problems [back to top]

Problem Code Start Date Resolved Date Status
Acute pyelonephritis 36689008 Active

Results [back to top]

Unknown or Not Available.

Active Medications [back to top]

Unknown or Not Available.

Medications Administered During Visit [back to top]

Unknown or Not Available.

Encounters [back to top]

Encounter Diagnosis Diagnosis Code Start Date
PNEUMONIA, ORGANISM NOS 486 03/19/2015

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 CLINTON COUNTY HOSPITAL on 03/19/2015 with a principal diagnosis of PNEUMONIA, ORGANISM NOS.

You had the following procedures done:

  • THER/PROPH/DIAG IV INF INIT
  • THER/PROPH/DIAG INJ IV PUSH
  • THER/PROPH/DIAG IV INF INIT
  • THER/PROPH/DIAG INJ IV PUSH
  • THER/PROPH/DIAG IV INF INIT
  • THER/PROPH/DIAG INJ IV PUSH
  • THER/PROPH/DIAG IV INF INIT
  • THER/PROPH/DIAG IV INF INIT

You were discharged from CLINTON COUNTY HOSPITAL on 03/23/2015.

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
RRL PNEUMONIA

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.