Continuity of Care Document 1357 Amber Dr Beaverton OR 97006 US Alice Jones Alicia Newman Neighborhood Physicians Practice 2472 Rocky Place Beaverton OR 97006 Neighborhood Physicians Practice 2472 Rocky Place Beaverton OR 1357 Amber Dr Beaverton OR 97006 US Matthew Newman 1357 Amber Dr Beaverton OR 97006 US Rick Holler 2472 Rocky Place Beaverton OR 97006 Albert Davis Neighborhood Physicians Practice 2472 Rocky Place Beaverton OR 97006
ALLERGIES, ADVERSE REACTIONS, ALERTS
Substance Status Reaction
Penicillin G Active Adverse Reaction
Ampicillin Active Adverse Reaction
MEDICATIONS
Medication Status Intent
Ceftriaxone 100 MG/ML Completed Order
Tylenol 500mg Completed Order
Ceftriaxone 100 MG/ML Tylenol 500mg
PROBLEMS LIST
Problem Status Clinical Status
Essential hypertension (disorder) Active active
Severe Hypothyroidism (disorder) Active active
Chronic rejection of renal transplant (disorder) Active active
Fever (finding) Active active
Overweight (finding) Active resolved
Food Insecurity (finding) Active active
PROCEDURES
Procedure Status
Nebulizer Therapy Completed
Introduction of cardiac pacemaker system via vein Completed
DIAGNOSTIC TEST RESULTS
Lab Test Result Value Status
EKG 0.4 seconds Final
Color of Urine YELLOW Final
Appearance of Urine CLEAR Final
Specific gravity of Urine by Test strip 1.015 1 Final
pH of Urine by Test strip 5.0 [pH] Final
Glucose [Mass/volume] in urine by test strip 50 mg/dL Final
Ketones [Mass/Volume] in urine by test strip Negative Final
Protein [Mass/Volume] in urine by test strip 100 mg/dL Final
Ms Alice Newman was tested for the Urinalysis macro panel and the results have been found to be normal. 0.4 seconds YELLOW CLEAR Negative
ASSESSMENT The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day.
VITAL SIGNS
Vital Sign Value Date
Height 177 cm 20150622100500-0500
Weight 88 kg 20150622100500-0500
Blood Pressure Diastolic 88 mm[Hg] 20150622100800-0500
Blood Pressure Systolic 145 mm[Hg] 20150622100800-0500
Heart Rate 80 /min 20150622101000-0500
O2 % BldC Oximetry 95 % 20150622101200-0500
Inhaled Oxygen Concentration 36 % 20150622101200-0500
Body Temperature 38 Cel 20150622101500-0500
Respiratory Rate 18 /min 20150622101500-0500
IMMUNIZATIONS
Vaccine Status Date
Tetanus and diphtheria toxoids Completed 20120104
influenza, intradermal, quadrivalent, preservative free Not Done 20150622
SOCIAL HISTORY
Social History Element Value Date
Smoking Status Current every day smoker 20150622100500-0500
Sex Observation Female (finding) 20150622100000-0500
Basic Occupation Odd Jobs Day Worker [Janitors and Cleaners, Except Maids and Housekeeping] 20150622100000-0500
Basic Occupation Industry Building cleaning services, interior [Janitorial Services ] 20150622100000-0500
Tribal Affiliation Cherokee Nation 20150622100000-0500
Pregnancy Status Not Pregnant 20150622100000-0500
Hunger Vital Signs [HVS] 2 (Integer) 20150622100000-0500
Worry food run out Often true 20150622100000-0500
Food didn't last Often true 20150622100000-0500
PLAN OF TREATMENT
Planned Activity Status Target Date
Get an EKG done on 6/23/2015 Planned 20150622
Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure Planned 20150622
Take Clindamycin 300mg three times a day as needed if pain does not subside Planned 20150622
Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015 Planned 20150622
Assistance with application for food pantry program Planned 20150622
i. Get an EKG done on 6/23/2015. ii. Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure. iii. Take Clindamycin 300mg three times a day as needed if pain does not subside. iv. Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015. Get an EKG done on 6/23/2015 Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure Take Clindamycin 300mg three times a day as needed if pain does not subside Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015
GOALS
Goal Description Status
History of Social function Active
Get rid of intermittent fever that is occurring every few weeks Active
Need to gain more energy to do regular activities Active
a. Get rid of intermittent fever that is occurring every few weeks. b. Need to gain more energy to do regular activities Get rid of intermittent fever that is occurring every few weeks Need to gain more energy to do regular activities
FUNCTIONAL STATUS
Functional/Disability Status Status Date
Dependence on Cane Active 20150622100000-0500
Disability Status Active 20150622100000-0500
PAYERS
Payer Policy Type Date
Government-funded (other than Medicare or Medicaid) Government-funded (other than Medicare or Medicaid) 20150101
Government-funded Payer
PROCEDURE NOTE
Summary Written by: Date
Dr Albert Davis examined Ms Alice Newman and found that the pacemaker is operating properly and the breathlessness is due to high fever and anxiety. Dr Albert Davis 06/22/2015
Dr Albert Davis examined Ms Alice Newman and found that the pacemaker is operating properly and the breathlessness is due to high fever and anxiety.
PROGRESS NOTE
Summary Written by: Date
Ms Alice Newman seems to be developing high fever and hence we recommend her to get admitted to a nearby hospital using the provided referral. Dr Albert Davis 06/22/2015
Ms Alice Newman seems to be developing high fever and hence we recommend her to get admitted to a nearby hospital using the provided referral.
REFERRAL NOTE
Summary Written by: Date
Ms Alice Newman is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia. Dr Albert Davis 06/22/2015
Ms Alice Newman is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia.
HEALTH CONCERNS a. Chronic Sickness exhibited by patient b. HealthCare Concerns refer to underlying clinical factsi. Documented HyperTension problemii. Documented HypoThyroidism problemiii. Watch Weight of patient
Health Concern Status Date
Chronic Sickness exhibited by patient Active 20150622
Documented HyperTension problem Active 20150622
Documented HypoThyroidism problem Active 20150622
Watch Weight of patient Active 20150622
Nutrition impaired due to limited access to healthful foods Active 20150622
Food insecurity Active 20150622