Patient Summary (HL7 CCD)

Document Effective: 11/19/2015 06:42

Encounter Dates:11/17/2015 through 11/17/2015

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?
Height (Lying) 63 in 11/17/2015 15:59 Most Recent VS
Height 53 in 11/17/2015 15:59 Initial VS
Weight Measured 205 lbs 11/17/2015 15:59 Initial VS
BMI (Body Mass Index) 51.31 kg/m^2 11/17/2015 15:59 Initial VS
BSA (Body Surface Area) 1.86 m^2 11/17/2015 15:59 Initial VS
BP Systolic 112 mmHg 11/17/2015 15:59 Initial VS
BP Diastolic 60 mmHg 11/17/2015 15:59 Initial VS
Respiratory Rate 18 bpm 11/17/2015 15:59 Initial VS
Heart Rate 72 bpm 11/17/2015 15:59 Initial VS
O2 % BldC Oximetry 96 % 11/17/2015 15:59 Initial VS
Body Temperature 97.8 degrees 11/17/2015 15:59 Initial 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
Introduction of Other Therapeutic Substance into Subcutaneous Tissue, Percutaneous Approach 3E013GC ICD-10 PCS 11/17/2015

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]


BUN CREA - Collect Date/Time: 11/17/2015 15:30
Test Name Code Test Result Test Units Test Ref Range
BUN 3094-0 23 mg/dl L=7 H=20
CREATININE 2160-0 0.8 mg/dl L=0.5 H=1.1
AGE 30525-0 69 YRS
EST GFR NONAA 48642-3 102
RACE WHITE N/A

IONIZED CALCIUM - Collect Date/Time: 11/17/2015 15:30
Test Name Code Test Result Test Units Test Ref Range
IONIZED CALCIUM 1994-3 1.30 mmol/L L=1.12 H=1.32
IONIZED CA++(CALC) 5.20 mg/dl L=4.48 H=5.28

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
Age-related osteoporosis without current pathological fracture M810 11/17/2015

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 11/17/2015 with a principal diagnosis of Age-related osteoporosis without current pathological fracture.

You had the following procedures done:

  • THER/PROPH/DIAG INJ SC/IM

You were discharged from CLINTON COUNTY HOSPITAL on 11/17/2015.

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
OSTEOPORSIS SENILE

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.