632768297865636250 English V1.0 2006-03-01T16:09:46Z AA0001 AA0002 Primary Care Provider AA0003 AA0004 AA0005 Consulting Provider 2006-03-23 Request For Consult AA0002 BB0006 AA0002 BB0009 BB0001 Effective Date 2005-07-01T04:00:00Z Termination Date 2006-05-31T04:00:00Z Plan Code 584 AA0002 Policy Number 079087 AA0002 Group Number 9023q4785 AA0002 Group Name Default AA0002 Patient ID 97865432567896543 AA0002 Primary Health Insurance AA0002 AA0006 Payer AA0007 BB0002 Policy Number N/A AA0002 Guarantor AA0008 AA0009 BB0003 Recorded Date 2005-06-30T04:00:00Z CPR Status Cardioversion Only Comment Family history of poor outcome after CPR. Prolonged suffering Current and Verified AA0002 BB0004 Recorded Date 2005-07-05T04:00:00Z Antibiotic Status Antibiotics Only Current and Verified AA0010 AA0011 Durable Power of Attorney for Healthcare BB0005 Onset 32 Years Mobility Limited Chronic AA0002 BB0006 Onset 1999-03-31T05:00:00Z Diagnosis Congestive Heart Failure 428.0 ICD9-CM 2005 Active AA0010 BB0007 Onset 1984-02-29T05:00:00Z Diagnosis Diabetes Mellitus 250.02 ICD9-CM 2005 Active AA0010 BB0008 Onset 1990-08-07T04:00:00Z Diagnosis Hypertension 403.10 ICD9-CM 2005 Active AA0010 BB0009 Onset 2003-01-24T05:00:00Z Diagnosis Myocardial Infarction 410.80 ICD9-CM 2005 Active AA0010 BB0010 Onset 2005-09-23T04:00:00Z Active AA0012 AA0013 Mother 70 Years Ill AA0012 AA0002 Problem ANEMIA UNSPECIFIED 285.9 ICD9-CM 2005 AA0012 BB0011 Marital Status Married AA0002 BB0012 Language English AA0002 BB0013 Ethnicity Other AA0002 BB0014 Religious Preference Catholic AA0002 BB0015 Pregnancies 4 AA0002 BB0016 Term Pregnancies 3 AA0002 BB0017 Pre-term Pregnancies 1 AA0002 BB0018 Birth History Nvdx3 AA0002 BB0019 Employment Full-time AA0002 AA0014 Employer BB0020 Date of Onset 19 Years Tobacco Use Type: Cigarettes<br>Frequency: 1 pack / day Type Cigarettes Frequency 1 pack / day Current AA0012 BB0021 Initial Occurrence 1970-01-14T05:00:00Z Allergy Penicillins 245 FDB ALLERGY 2005 294513009 SNOMED CT 2005 C0571425 UMLS Concept 2005 Current AA0012 BB0022 Penicillins AA0012 Penicillins Rash/Eruption Severe BB0023 Initial Occurrence 2005-03-28T05:00:00Z Allergy Sulfa (Sulfonamides) 305 FDB ALLERGY 2005 Current AA0010 BB0024 Sulfa (Sulfonamides) AA0010 Sulfa (Sulfonamides) Fever Moderate BB0025 Initial Occurrence 2 years ago Allergy Ragweed 152 E-MDS ALLERGY 2005 Current AA0012 BB0026 Ragweed AA0012 Ragweed Congestion Mild BB0027 Prescription Date 2005-03-28T05:00:00Z Medication Active AA0010 metformin RX10006809 RXNORM 2005 Glucophage XR 00087606313 NDC 2005 500 mg
tablet, extended release
100 tablet 1 tablet PO bid 1 tablet PO bid AA0002 BB0007 Hold dose if patient becomes markedly light headed. 0 BB0028 Prescription Date 2005-07-21T04:00:00Z Medication Active AA0010 ezetimibe-simvastatin Vytorin 66582031231 NDC 2005 10 mg 20 mg
tablet
50 tablet 1 tablet PO bid 1 tablet PO bid AA0002 BB0006 0 BB0029 Prescription Date 2005-10-28T04:00:00Z Medication Active AA0010 insulin lispro RX10086009 RXNORM 2005 Humalog 00002751001 NDC 2005 100 units/mL
injection
100 injection 0 unit OR 0 unit AA0002 BB0007 1 OR SIG Specifier FBS<80 1 unit ac OR 1 unit ac AA0002 BB0007 2 OR SIG Specifier FBS 80-120 2 unit ac OR 2 unit ac AA0002 BB0007 3 OR SIG Specifier FBS 121-160 3 unit ac OR 3 unit ac AA0002 BB0007 4 OR SIG Specifier FBS 161-200 4 unit ac OR 4 unit ac AA0002 BB0007 5 OR SIG Specifier FBS 201-250 5 unit ac OR 5 unit ac AA0002 BB0007 6 OR SIG Specifier FBS 251-300 6 unit ac 6 unit ac AA0002 BB0007 0 BB0030 Prescription Date 2005-10-28T04:00:00Z Medication Active AA0010 predniSONE RX10008640 RXNORM 2005 PredniSONE 00054474125 NDC 2005 1 mg
tablet
15 tablet 5 tablet PO qd 1 Days THEN 5 tablet PO qd 1 Days 1 THEN 4 tablet PO qd 1 Days THEN 4 tablet PO qd 1 Days 2 THEN 3 tablet PO qd 1 Days THEN 3 tablet PO qd 1 Days 3 THEN 2 tablet PO qd 1 Days THEN 2 tablet PO qd 1 Days 4 THEN 1 tablet PO qd 1 Days 1 tablet PO qd 1 Days 0 BB0031 Prescription Date 2005-10-28T04:00:00Z Medication Active AA0010 nafcillin RX10007233 RXNORM 2005 Nafcillin Sodium 00338101741 NDC 2005 1 g/50 mL
solution
1 100 ml IVPB q4h 100 ml IVPB q4h 0 BB0032 Prescription Date 2005-10-28T04:00:00Z Medication Active AA0010 influenza virus vaccine, live, trivalent FluMist 66019010001 NDC 2005
spray
1 spray 1 spray NAS 1 spray NAS 0 BB0033 Immunization Date 2005-09-22T02:00:00Z Immunization AA0012 Influenza 15 HL7 CVX 2.5 C1548663 UMLS Concept ID 2005
Split virus, 6-35 mo. dosage
ID Left arm BB0034 Assessment Time 2005-09-24T02:00:00Z Height & Weight AA0012 BB0035 Observation Height 50373000 SNOMED 2005 AA0002 155 cm BB0036 Observation Weight 363808001 SNOMED 2005 AA0002 55 kg BB0037 Assessment Time 2005-09-24T02:00:00Z Cardiac Monitoring AA0012 BB0038 Result Heart Rate 364075005 SNOMED 2005 AA0002 73 /min BB0039 Assessment Time 2005-09-24T02:00:00Z Blood Pressure AA0012 BB0040 Result Systolic 271649006 SNOMED 2005 AA0002 130 mm Hg BB0041 Result Diastolic 271650006 SNOMED 2005 AA0002 90 mm Hg BB0042 Assessment Time 2005-09-24T02:00:00Z Respiratory Rate AA0012 BB0043 Result Respiratory Rate 86290005 SNOMED 2005 AA0002 23 /min BB0044 Ob/Gyn Observations AA0002 BB0045 Observation Pregnancy State AA0002 No BB0046 2005-09-12 Observation LMP AA0002 9/12/2005 BB0047 Assessment Time 2003-12-08T04:00:00Z Complete cbc w/auto diff wbc AA0007 BB0048 Result Spun microhematocrit AA0002 32.6 L/L Abnormal Low BB0049 Result plasma hemoglobin AA0002 9.6 G/L Abnormal Low BB0050 Result Automated leukocyte count AA0002 18.5 10^3/uL Abnormal High BB0051 Assessment Time 2005-10-29T02:00:00Z Urine culture/colony count 87086 CPT 2005 C0374001 UMLS Concept 2005 AA0010 BB0052 Result Urine culture/colony count AA0002 <p><span id="_ctl0_OrderCompletionListControl1_DataListOrders__ctl1_DataListRequestOrders__ctl0_DataGridNondiscreteResultDetail__ctl2_LabelNondiscreteResultReport">FINAL REPORT *** </span></p> <p><span>Culture Results Enterobacter aerogenes - GREATER THAN 100 X 10^6 COLONY FORMING UNITS (CFU)/L *** Sensitivity Results *** Organism :Entero aerogenes ANTIMICROBIAL THERAPEUTIC DOSE MIC BLOOD URINE ----------------------------------------------------------------------</span></p> <p><span>AMPICILLIN NC &gt;16 R R GENTAMICIN NC &lt;=4 S S TOBRAMYCIN NC &lt;=4 S S SEPTRA NC &lt;=.5/9.5 S S NITROFURANTOIN NC &lt;=32 S </span></p> Normal BB0053 Assessment Time 2005-10-29T02:00:00Z Urinalysis, nonauto w/scope 81000 CPT 2005 C0373517 UMLS Concept 2005 AA0010 BB0054 Result Urine Bilirubin AA0002 Negative Normal BB0055 Result Urine Epithelial AA0002 Few Normal BB0056 Result Bone marrow biopsy AA0002 Negative Normal BB0057 Result Urine Protein AA0002 Negative Normal BB0058 Result Urine appearance AA0002 Clear Normal BB0059 Result Color AA0002 Yellow Normal BB0060 Result Specific Gravity AA0002 1.005 Normal BB0061 Result URINE PH AA0002 7.00 Normal BB0062 Result Urine WBC's AA0002 Few Normal BB0063 Result Urine RBC's AA0002 Few Normal BB0064 Procedure Date 2005-09-23T04:00:00Z Surgical CABG, arterial, two 33534 CPT 2005 C0371565 UMLS Concept 2005 AA0010 AA0002 BB0006 BB0065 Procedure Date 2006-03-01T05:00:00Z Surgery Tenotomy, adductor of hip, open 27001 CPT 2005 76453002 SNOMED CT 2005 C0186106 UMLS Concept 2005 Completed AA0002 open right lateral decubitus left hip BB0066 Encounter Date 2005-09-23T04:00:00Z Emergency Chest pain AA0010 Broward Medical Center AA0015 Practitioner AA0002 BB0006 BB0067 Encounter Date 2005-09-04T04:00:00Z Outpatient Chest pain evaluation AA0010 CCR Physician Group AA0016 Practitioner AA0002 BB0006 BB0068 Treatment Recommendation Diabetic retinal evaluation In Process AA0010 BB0069 Patients &gt;10 years of age with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 3&#8211;5 years after the onset of diabetes. In general, screening for diabetic eye disease is not necessary before 10 years of age. AA0010 BB0070 Order A1C Monitoring In Process AA0010 BB0071 AA0010 BB0072 Lab Glycated hemoglobin test 83036 CPT 2005 C0373638 UMLS Concept 2005 AA0010 8 Weeks 52 Weeks AA0002 BB0007 AA0017 Consulting Provider AA0016 Consulting Provider AA0010 Primary Care Provider AA0001 Jane B Hernandez 1948-01-16T04:00:00Z Female SSN 888-88-8888 AA0002
Home 758 Las Olas Dr. Fort Lauderdale FL 33011
555-555-5555 Home 666-666-6666 Alternate 444-444-4444 Mobile 333-333-3333 Pager none@nowhere.com AA0002 AA0002 Steven Waldren Dr. Steven Waldren Family Practice swaldren@aafp.org AA0002 AA0003 Center for Health Information Technology - AAFP
Main 406 Copperline Dr. Chapel Hill NC 27516
919-960-5290 Main 913-215-7968 Mobile dkibbe@aafp.org AA0002 AA0004 Solventus CCR ViewPort V1.0 AA0002 AA0005 David Chase Kibbe Dr. David Kibbe Family Practice
Home 406 Copperline Dr. Chapel Hill NC 27516
919-960-5290 Home 913-215-7968 Mobile dkibbe@aafp.org AA0002 AA0006 Blue Cross Blue Shield of Florida BlueScript AA0002 AA0007 Steven Hernandez 1968-08-20T04:00:00Z Male SSN 151436167 AA0002 AA0002 AA0008 John Adam Smith Dr. John Smith
Home 94044 Link Road San Francisco CA 94304
415-555-1212 Home jsmith@ccrdemohealthclinic.com AA0002 AA0009 John Rivera 1965-01-03T04:00:00Z Sibling AA0002 AA0010 Peter Primary Dr. Peter Primary ccrfp@hotmail.com AA0002 AA0011 Rita Ribera
Home 1822 McNab Ave Fort Lauderdale FL 33072
AA0002 AA0012 John Gray Dr. John Gray
Home 800 E Las Olas Blvd Fort Lauderdale FL 33301
954-555-1212 Home ken.miller@solventus.com AA0002 AA0013 Unknown Mother AA0002 AA0014 Acme Corp.
Main 2000 N Flagler Dr. Miami FL 33044
AA0002 AA0015 Stephen Goldberg AA0002 AA0016 Myron Mitral Dr. Myron Mitral ccrcardio@hotmail.com AA0002 AA0017 Gary Ganglion Dr. Gary Ganglion ccrneuro@hotmail.com AA0002