Department of Veterans Affairs Prepared ONE … · Jan 05, 2017 Provider One PORTLAND VA MEDICAL CENTER ST. JOHN'S WORT CAP/TAB Non-VA TAKE 1 CAP/TAB BY MOUTH AT BEDTIME Non-VA Documented

for Prepared ONE MHVTESTVETERAN

DOB: March 1, 1948

Birth Sex: Male

Department of Veterans Affairs

Department of Veterans Affairs Health Summary

created on August 8, 2017, 08:39:15, EST

Table of Contents

Patient Information Allergies Problems Medications Vital Signs Results Immunizations Encounters Procedures

Plan of Care Functional Status Family History Social History Insurance Providers Advance Directive Healthcare Providers

Contact Information

Patient Information

Address Primary Home:

123 ANYWHERE RD

APT 123

WASHINGTON, DC 20420

Tel: +1-000-020-0202

Marital status DIVORCED

Race White

Ethnicity Not Hispanic or Latino

Language(s)

Preferred Language

Allergies

ONE MHVTESTVETERAN CONFIDENTIAL Page 1 of 44

VA Health Summary (Continuity of Care Document)

This section contains Allergies on record with VA for the patient. The data comes from all VA treatment facilities. It does not list allergies that were

removed or entered in error. Some allergies may be reported in the Immunization section.

Allergen Event Date Event Type Reaction(s) Severity Source

BACTRIM Jun 03, 2011 Propensity to adverse reactions to drug PORTLAND VA MEDICAL CENTER

IMIPRAMINE Dec 07, 2012 Propensity to adverse reactions to drug ANAPHYLAXIS SEVERE PORTLAND VA MEDICAL CENTER

OXYCODONE Jan 04, 2017 Propensity to adverse reactions to drug PORTLAND VA MEDICAL CENTER

PENICILLIN Jan 04, 2017 Propensity to adverse reactions to drug GENERALIZED RASH PORTLAND VA MEDICAL CENTER

TERAZOSIN Jun 03, 2011 Propensity to adverse reactions to drug DIZZINESS PORTLAND VA MEDICAL CENTER

TETRACYCLINE Jan 15, 2016 Propensity to adverse reactions to drug ANAPHYLAXIS SEVERE PORTLAND VA MEDICAL CENTER

TRAMADOL Jun 03, 2011 Propensity to adverse reactions to drug RETENTION OF URINE PORTLAND VA MEDICAL CENTER

TRIHEXYPHENIDYL May 05, 2017 Propensity to adverse reactions to drug GENERALIZED RASH PORTLAND VA MEDICAL CENTER

TRIMETHOPRIM Jun 03, 2011 Propensity to adverse reactions to drug PORTLAND VA MEDICAL CENTER

Problems

This section contains a list of Problems/Conditions known to VA for the patient. It includes both active and inactive problems/ conditions. The data comes

from all VA treatment facilities. Available 3 calendar days after entry.



Problem StatusProblem

Code

Date

of

Onset

Date of

ResolutionComment(s) Provider Source

Ankylosing spondylitis (SCT 9631008) Active 9631008 No comments entered for problem.Provider One

PORTLAND

VA

MEDICAL

CENTER

Congestive heart failure (SCT 42343007) Active 42343007 No comments entered for problem.Provider One

PORTLAND

VA

MEDICAL

CENTER

Diabetes with neurological Manifestations, type

i [Juvenile type], not stated as (ICD-9-CM

250.61)

Active 421468001 No comments entered for problem.Provider One

PORTLAND

VA

MEDICAL

CENTER

Ehlers-Danlos syndrome, type 8 (SCT

50869007)Active 50869007 No comments entered for problem.

Provider OnePORTLAND

VA

MEDICAL

CENTER

Hyperlipidemia (ICD-9-CM 272.4) Active 272.4 No comments entered for problem.Provider One

PORTLAND

VA

MEDICAL

CENTER

Mild cognitive impairment (SCT 386805003) Active 386805003

Jan 16, 2013 Entered By: Provider One Comment: INDEPENDENT IN

ADLs AND IADLs Dec 10, 2012

Entered By: Provider One Comment:

this is only a test


VA

MEDICAL

CENTER

Feb 11, 2013 Entered By:



Posttraumatic Stress Disorder (ICD-9-CM

309.81)Active 47505003

Provider One Comment: comment #3

Feb 11, 2013 Entered By: Provider One Comment: Comment #2

Feb 11, 2013 Entered By: Provider One Comment: comment #1

Jan 16, 2013 Entered By: Provider One Comment: AWAITING A COMP AND PEN EXAM


VA

MEDICAL

CENTER

TRAUMATIC BRAIN INJURY (ICD-9-CM

799.9)Active 799.9 No comments entered for problem.


VA

MEDICAL

CENTER

Temporal lobectomy behavior syndrome (SCT

10651001)Active 10651001 No comments entered for problem.


VA

MEDICAL

CENTER

Wolff-Parkinson-White pattern (SCT 74390002) Active 74390002 No comments entered for problem.Provider One

PORTLAND

VA

MEDICAL

CENTER

Lack of Housing (ICD-9-CM V60.0) Inactive 160701002Dec 10,

2012No comments entered for problem.


VA

MEDICAL

CENTER

Medications

This section contains: 1) prescriptions processed by a VA pharmacy in the last 15 months, and 2) all medications recorded in the VA medical record as



non-VA medications. Pharmacy terms refer to VA pharmacys work on prescriptions. VA patients are advised to take their medications as instructed by

their health care team. Data comes from all VA treatment facilities.

Glossary of Pharmacy Terms: Active=A prescription that can be filled at the local VA pharmacy. Active: On Hold= An active prescription that will not be

filled until pharmacy resolves the issue. Active: Susp= An active prescription that is not scheduled to be filled yet. Clinic Order: A medication you received

during a visit to a VA clinic or emergency department. Discontinued=A prescription stopped by a VA provider. It is no longer available to be filled.

Expired=A prescription which is too old to fill. This does not refer to the expiration date of the medication in the container. Non-VA=A medication that came

from someplace other than a VA pharmacy. This may be a prescription from either the VA or other providers that was filled outside the VA. Or, it may be

an over the counter (OTC), herbal, dietary supplement or sample medication. Pending=This prescription order has been sent to the Pharmacy for review

and is not ready yet.

Medication Name

and Strength

Pharmacy

TermInstructions

Quantity

Ordered

Prescription

Expires

Prescription

Number

Last

Dispense

Date

Ordering Provider Facility

ACETAMINOPHEN

325MG TABExpired

TAKE 325-650MG BY MOUTH EVERY 4 TO 6

HOURS AS NEEDED *PATIENTS WITHOUT

LIVER DISEASE, MAXIMUM DOSE IS 4

GM/DAY OF ACETAMINOPHEN. FOR PAIN.

THIS IS ONLY A TEST

100Jan 15,

201712288668

Sep 15,

2016


VA

MEDICAL

CENTER

ALLOPURINOL

300MG TABActive

TAKE ONE TABLET BY MOUTH EVERY DAY

TO LOWER URIC ACID LEVELS IN BLOOD90

Jan 06,

201812659470

Jan 05,

2017


VA

MEDICAL

CENTER

ASCORBIC ACID

500MG TABDiscontinued


TAKE WITH IRON (FERROUS SULFATE)

TABLET.

100May 06,

201812788031

May 05,

2017


VA

MEDICAL

CENTER

FERROUS SO4

325MG TABActive TAKE ONE TABLET BY MOUTH TWICE A DAY 200

Jan 06,

201812659471

Jan 05,

2017


VA

MEDICAL

CENTER

Documented by:

Documented

at:



FISH OIL CAP/TAB Non-VA TAKE 1 CAP/TAB BY MOUTH EVERY DAY Non-VA Provider One PORTLAND

VA

MEDICAL

CENTER

FOLIC ACID 1MG

TABActive TAKE ONE TABLET BY MOUTH EVERY DAY 100

May 06,

201812788033

May 05,

2017


VA

MEDICAL

CENTER

FUROSEMIDE 20MG

TABExpired

TAKE ONE-HALF TABLET BY MOUTH EVERY

DAY FOR HEART FAILURE THIS IS ONLY A

TEST

15Jan 15,

201712288670

Sep 17,

2016


VA

MEDICAL

CENTER

GINKGO EXT 60MG

TABNon-VA

TAKE SMALL AMOUNT BY MOUTH EVERY

DAYNon-VA

Documented by: Provider One

Documented

at:

PORTLAND

VA

MEDICAL

CENTER

GLIPIZIDE 5MG TAB Discontinued


FOR DIABETES. TAKE 30 MINUTES BEFORE A

MEAL.

90Jan 06,

201812659467

Jan 05,

2017


VA

MEDICAL

CENTER

KAVA CAP/TAB Non-VA TAKE 1 CAP/TAB BY MOUTH EVERY DAY Non-VA


Documented

at:

PORTLAND

VA

MEDICAL

CENTER

LEVOTHYROXINE

NA 0.025MG TAB

(SYNTHROID)

Active: On

Hold


ON AN EMPTY STOMACH AND AT LEAST 4

HOURS BEFORE PRODUCTS CONTAINING

CALCIUM, IRON OR VITAMINS

90Jan 06,

201812659472

Jan 01,

2017


VA

MEDICAL

CENTER

Documented



LISINOPRIL 5MG

TAB Non-VATAKE ONE-HALF TABLET BY MOUTH EVERY

DAY Non-VA


at:

PORTLAND

VA

MEDICAL

CENTER

SAW PALMETTO

CAP/TABNon-VA TAKE 1 TAB BY MOUTH AT BEDTIME Non-VA


Documented

at:

PORTLAND

VA

MEDICAL

CENTER

SIMVASTATIN 20MG

TABExpired

TAKE ONE TABLET BY MOUTH EVERY

EVENING TO LOWER YOUR CHOLESTEROL.

AVOID CONSUMING GRAPEFRUIT

PRODUCTS.

90Jan 06,

201812659474

Jan 05,

2017


VA

MEDICAL

CENTER

ST. JOHN'S WORT

CAP/TABNon-VA TAKE 1 CAP/TAB BY MOUTH AT BEDTIME Non-VA


Documented

at:

PORTLAND

VA

MEDICAL

CENTER

VITAMIN A

10000UNT CAPActive

TAKE 10000UNT BY MOUTH EVERY DAY

DOSES OVER 25,000 UNITS/DAY ARE

CONTRAINDICATED IN PREGNANCY

90May 06,

201812788035

May 05,

2017


VA

MEDICAL

CENTER

CHOLECALCIFEROL

400UNT TAB

Active: On

HoldTAKE 400UNT BY MOUTH EVERY DAY 100

May 06,

201812788038

Jan 01,

2017


VA

MEDICAL

CENTER

VITAMIN E 200UNT

CAPExpired TAKE 200UNT BY MOUTH EVERY DAY 100

Aug 03,

201712788039

May 05,

2017


VA

MEDICAL

CENTER



Vital Signs

The included list of inpatient and outpatient Vital Signs is from the last 12 months and includes a maximum of the 5 most recent sets of vital sign values. If

more than one set of vitals was taken on the same date, only the most recent set is populated for that date. The data comes from all VA treatment

facilities.

Date/Time Temperature PulseBlood

Pressure

Respiratory

RateSP02 Pain Height Weight

Body Mass

IndexSource

May 05, 2017, 12:08

PM101.5 F

120

/min90/60 mm[Hg] 23 /min 98 % 10 76 in 180 lb 22

PORTLAND VA MEDICAL

CENTER

Jan 05, 2017, 06:46 AM 102.2 F120

/min82/40 mm[Hg] 22 /min 75 % 10

PORTLAND VA MEDICAL

CENTER

Results

This section contains the Chemistry and Hematology Lab Results, Radiology Reports, and Pathology Reports on record with VA for the patient. The data

comes from all VA treatment facilities.

Lab Results

The included Chemistry/Hematology Results are from the last 24 months, are available 3 calendar days after verification, and include a maximum of the 10 most recent sets of

tests. The data comes from all VA treatment facilities.

Date/Time Source Result Type Result - Unit InterpretationReference

RangeComment

May 05,

2017,

12:42 PM

PORTLAND

VA

MEDICAL

CENTER

CBC with Auto

Diff

Specimen Type: BLOOD

Comment: Ordering Provider: Provider One Report Released Date/Time: May 05, 2017@12:45

Performing Lab: PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131] 3710 SW US VETERANS HOSPTL RD PORTLAND, OR 97239-2964



WBC 45.010*3/uL H 4.4-10.8

RBC 4.0010*6/uL L 4.3-5.6

HGB 14.6g/dL 13-17.4

HCT 45.0% 41-51

MCV 90.0fl 82.0-98.0

MCH 25pg L 28-34.0

MCHC 33g/dL 33-37

RDW 14.0% 11.5-14.5

PLT 56810*3/uL H 150-400

MPV 8fl 7.4-10.4

LY% 25% 15-42

LY# 2510*3/uL H 1.0-4.0

NE# 5510*3/uL H 2.5-7.0

NE% 55% 44-78

MO# 1410*3/uL H 0.2-1.0

MO% 14% H 3-12

EO# 310*3/uL H 0-0.5

BA# 210*3/uL H 0-0.2

EO% 3% 0-6

BA% 2% 0-2



May 05,

2017,

12:42 PM

PORTLAND

VA

MEDICAL

CENTER

CBC


Comment: Ordering Provider: Provider One Report Released Date/Time: May 05,

2017@12:45

Performing Lab: PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131]

3710 SW US VETERANS HOSPTL RD PORTLAND, OR 97239-2964

WBC 45.010*3/uL H 4.4-10.8

RBC 4.0010*6/uL L 4.3-5.6

HGB 14.6g/dL 13-17.4

HCT 45.0% 41-51

MCV 90.0fl 82.0-98.0

MCH 25pg L 28-34.0

MCHC 33g/dL 33-37

RDW 14.0% 11.5-14.5

PLT 56810*3/uL H 150-400

MPV 8fl 7.4-10.4

May 05,

2017,

12:42 PM

PORTLAND

VA

MEDICAL

CENTER

ZZCHEM 8

PANEL

Specimen Type: PLASMA

Comment: Called Critical CO2 Ordering Provider: Provider One Report Released Date/Time: May 05, 2017@12:44


CALCIUM 8.8mg/dL 8.4-10.4

PHOSPHATE 3.4mg/dL 2.5-4.5

CHOLESTEROL 600mg/dL H 1-240

PROTEIN,TOTAL 4.5g/dL L 6.5-8.2



ALBUMIN 6.0g/dL H 3.4-5.0

BILIRUBIN,

TOTAL2.3mg/dL H 0.2-1.1

ALKALINE

PHOSPHATASE249IU/L H 45-129

SGOT (AST) 500IU/L H 14-44

May 05,

2017,

12:42 PM

PORTLAND

VA

MEDICAL

CENTER

BASIC

METABOLIC

PANEL


Comment: Called Critical CO2 Ordering Provider: Provider One Report Released Date/Time: May 05, 2017@12:44


GLUCOSE 397mg/dL H 71-109

UREA

NITROGEN50mg/dL H 7-23

CREATININE 3.4mg/dL H 0.8-1.5

SODIUM 140mmol/L 131-142

POTASSIUM 4.0mmol/L 3.5-5.0

CHLORIDE 118mmol/L H 95-108

CO2 45mmol/L H* 21-32


ANION GAP 5mmol/L L 10-22

EGFR 18 L

Jan 05,

2017,

PORTLAND

VA

MEDICALZZCHEM 8


Comment: Test patient for Provider One. Ordering Provider: Provider One Report

Released Date/Time: Jan 05, 2017@11:50



10:00 AM CENTER PANEL Performing Lab: PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131]



PHOSPHATE 6.0mg/dL H 2.5-4.5

CHOLESTEROL 189mg/dL 1-240

PROTEIN,TOTAL 5.6g/dL L 6.5-8.2

ALBUMIN 3.2g/dL L 3.4-5.0

BILIRUBIN,

TOTAL1.0mg/dL 0.2-1.1

ALKALINE

PHOSPHATASE125IU/L 45-129


Jan 05,

2017,

10:00 AM

PORTLAND

VA

MEDICAL

CENTER

BASIC

METABOLIC

PANEL


Comment: Test patient for Provider One. Ordering Provider: Provider One Report

Released Date/Time: Jan 05, 2017@11:50



UREA

NITROGEN20mg/dL 7-23


SODIUM 145mmol/L H 131-142

POTASSIUM 3.9mmol/L 3.5-5.0

CHLORIDE 121mmol/L H 95-108



CO2 32mmol/L 21-32


ANION GAP 11mmol/L 10-22

EGFR 33 L

Jan 05,

2017,

10:00 AM

PORTLAND

VA

MEDICAL

CENTER

CBC with Auto

Diff


Comment: Test patient for Provider One. WBC reported incorrectly as 8.4 by

[197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. RBC reported incorrectly as 3.59 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. RBC flagged incorrectly as L by [197557-VA648]. Abnormal flag removed on Jan 09, 2017@08:04 by [256510-VA648]. HGB reported incorrectly as 11.1 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. HGB flagged incorrectly as L by [197557-VA648]. Abnormal flag removed on Jan 09, 2017@08:04 by [256510-VA648]. HCT reported incorrectly as 33.8 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by

[256510-VA648]. HCT flagged incorrectly as L by [197557-VA648]. Abnormal flag removed on Jan 09, 2017@08:04 by [256510-VA648]. MCV reported incorrectly as 94.0 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by

[256510-VA648]. MCH reported incorrectly as 31.0 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. MCHC reported incorrectly as 33.0 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. RDW reported incorrectly as 13.3 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. PLT reported incorrectly as 186 by

[197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. MPV reported incorrectly as 9.5 by [197557-VA648]. Changed to canc on Jan 09,

2017@08:04 by [256510-VA648]. Ordering Provider:Provider One Report Released

Date/Time: Jan 09, 2017@08:04



WBC canc10*3/uL 4.4-10.8

RBC canc10*6/uL 4.3-5.6

HGB cancg/dL 13-17.4

HCT canc% 41-51



MCV cancfl 82.0-98.0

MCH cancpg 28-34.0

MCHC cancg/dL 33-37

RDW canc% 11.5-14.5

PLT canc10*3/uL 150-400

MPV cancfl 7.4-10.4

LY% 29.6% 15-42

LY# 2.510*3/uL 1.0-4.0

NE# 5.010*3/uL 2.5-7.0

NE% 59.7% 44-78

MO# 0.710*3/uL 0.2-1.0

MO% 7.8% 3-12

EO# 0.110*3/uL 0-0.5

BA# 0.110*3/uL 0-0.2

EO% 1.8% 0-6

BA% 1.1% 0-2


Comment: Test patient for Provider One. WBC reported incorrectly as 8.4 by

[197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. RBC reported incorrectly as 3.59 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. RBC flagged incorrectly as L by [197557-VA648]. Abnormal flag removed on Jan 09, 2017@08:04 by [256510-VA648]. HGB reported incorrectly as 11.1 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. HGB flagged incorrectly as L by [197557-VA648]. Abnormal flag



Jan 05,

2017,

10:00 AM

PORTLAND

VA

MEDICAL

CENTER

CBC

removed on Jan 09, 2017@08:04 by [256510-VA648]. HCT reported incorrectly as 33.8 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by

[256510-VA648]. HCT flagged incorrectly as L by [197557-VA648]. Abnormal flag removed on Jan 09, 2017@08:04 by [256510-VA648]. MCV reported incorrectly as 94.0 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by

[256510-VA648]. MCH reported incorrectly as 31.0 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. MCHC reported incorrectly as 33.0 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. RDW reported incorrectly as 13.3 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. PLT reported incorrectly as 186 by

[197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. MPV reported incorrectly as 9.5 by [197557-VA648]. Changed to canc on Jan 09,

2017@08:04 by [256510-VA648]. Ordering Provider: Provider One Report Released

Date/Time: Jan 09, 2017@08:04



WBC canc10*3/uL 4.4-10.8

RBC canc10*6/uL 4.3-5.6

HGB cancg/dL 13-17.4

HCT canc% 41-51

MCV cancfl 82.0-98.0

MCH cancpg 28-34.0

MCHC cancg/dL 33-37

RDW canc% 11.5-14.5

PLT canc10*3/uL 150-400

MPV cancfl 7.4-10.4

Jan 19,

2016,

PORTLAND

VA

MEDICAL ACCESSION


Comment: TEST DATA Ordering Provider: Provider One Report Released Date/

Time: Jan 19, 2016@08:14



08:01 AM CENTER Performing Lab: PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131]


WBC 4.410*3/uL 4.4-10.8

RBC 4.3010*6/uL 4.3-5.6

HGB 4.7g/dL L 13-17.4

HCT 4.8% L* 41-51

MCV 52.0fl L 82.0-98.0

MCH 51pg H 28-34.0

MCHC 50g/dL H 33-37

RDW 37.0% H 11.5-14.5

PLT 3810*3/uL L 150-400

MPV 39fl H 7.4-10.4

LY% 22% 15-42

LY# 2310*3/uL H 1.0-4.0

NE# 2110*3/uL H 2.5-7.0

NE% 20% L 44-78

MO# 2510*3/uL H 0.2-1.0

MO% 24% H 3-12

EO# 2710*3/uL H 0-0.5

BA# 2810*3/uL H 0-0.2

EO% 26% H 0-6



BA% 27% H 0-2

Jan 19,

2016,

08:01 AM

PORTLAND

VA

MEDICAL

CENTER

ACCESSION


Comment: test data Ordering Provider: Provider One Report Released Date/

Time: Jan 19, 2016@08:12



UREA

NITROGEN20mg/dL 7-23


SODIUM 119mmol/L L* 131-142

POTASSIUM 6.1mmol/L H* 3.5-5.0

CHLORIDE 94mmol/L L 95-108

CO2 33mmol/L H 21-32


PHOSPHATE 4.3mg/dL 2.5-4.5

CHOLESTEROL 210mg/dL 1-240

PROTEIN,TOTAL 8.1g/dL 6.5-8.2

ALBUMIN 4.3g/dL 3.4-5.0

BILIRUBIN,

TOTAL1.2mg/dL H 0.2-1.1

ALKALINE

PHOSPHATASE120IU/L 45-129




ANION GAP 10mmol/L 10-22

EGFR 60

Radiology Reports

The included Radiology Reports are from the last 24 months, are available 3 calendar days after completion, and include a maximum of the 5 most recent reports. The data


Result

Date/TimeResults Type (LOINC) Source Result Provider Status

May 05,

2017, 12:00

PM

CHEST 2 VIEWS PA&LATPORTLAND VA

MEDICAL CENTER

MHVTESTVETERAN,ONE A 666-66-1948 DOB-MAR 01, 1948 M

Exm Date: MAY 05, 2017@12:00

Req Phys: Provider One Pat Loc: 111A TEST

NOTE LOCATION (Req'g

Img Loc: PDX-RAY-X

Service: Unknown

(Case 2503 COMPLETE) CHEST 2 VIEWS

PA&LAT (RAD Detailed) CPT:71020

Reason for Study: Rule out pneumonia

Clinical History:

please result this test radiology order for VACO

Report Status: Verified Date Reported:

Date Verified: MAY 05, 2017

Verifier E-Sig:

Report:

Impression:

Test patient; no report necessary for dictation;

ADMIN complete.

XRAY,MISSING completed



Primary Diagnostic Code:

Primary Interpreting Staff:

Provider One, STAFF RADIOLOGIST VERIFIED

BY:

MISSING XRAY, Staff Physician

/JDA

Jan 05, 2017,

09:27 AM

UL ABDOMINAL LIMITED (BILE

DUCTS/GB/LIVER/PANCREAS/SPLEEN)

PORTLAND VA

MEDICAL CENTER

MHVTESTVETERAN,ONE A 666-66-1948

DOB-MAR 01, 1948 M

Exm Date: JAN 05, 2017@09:27

Req Phys: Provider One Pat Loc: ACCESS CENTER-X (Req'g Loc)

Img Loc: ULTRASOUND-X

Service: Unknown

(Case 1623 COMPLETE) UL ABDOMINAL

LIMITED (BILE DUCTS/(US Detailed) CPT:76705

Reason for Study: this is a test

Clinical History:

this is only a test


Date Verified: JAN 05, 2017

Verifier E-Sig:

Report:

Impression:


ADMIN complete.


Provider Onecompleted




Provider One, STAFF RADIOLOGIST Verified by

transcriptionist for Provider One/JDA

Jan 05, 2017,

09:26 AMABDOMEN 3 OR MORE VIEWS

PORTLAND VA

MEDICAL CENTER

MHVTESTVETERAN,ONE A 666-66-1948

DOB-MAR 01, 1948 M

Exm Date: JAN 05, 2017@09:26

Req Phys: Provider One Pat Loc: ACCESS CENTER-X (Req'g Loc)

Img Loc: PDX-RAY-X

Service: Unknown

(Case 1621 COMPLETE) ABDOMEN 3 OR MORE

VIEWS (RAD Inactive) CPT:74020

Reason for Study: abdominal pain

Clinical History:

r/o obstruction



Verifier E-Sig:

Report:

Impression:


ADMIN complete.



Provider One, STAFF RADIOLOGIST Verified by

transcriptionist for Provider One




DUNCAN MD

/JDA

Jan 15, 2016,

09:46 AMCHEST 2 VIEWS PA&LAT

PORTLAND VA

MEDICAL CENTER

MHVTESTVETERAN,ONE A 666-66-1948 DOB-MAR 01, 1948 M

Exm Date: JAN 15, 2016@09:46

Req Phys: Provider One Pat Loc: FAKE CLINIC

AREA 1475 (Req'g L

Img Loc: PDX-RAY-X

Service: Unknown

(Case 2946 COMPLETE) CHEST 2 VIEWS

PA&LAT (RAD Detailed) CPT:71020

Reason for Study: evaluate chf

Clinical History:

r/o CHF.



Verifier E-Sig:

Report:

Impression:


ADMIN complete.



Provider ONe, MD, CHIEF RADIOLOGIST Verified

by transcriptionist for Provider One/JDA

BOUCHER,RONALD

Jcompleted



Pathology Reports

The included Pathology Reports are from the last 24 months, are available 14 calendar days after completion, and include a maximum of the 5 most recent reports. The data


Result

Date/Time

Results Type

(LOINC)Source Result Provider Status

LOCAL TITLE: LR SURGICAL PATHOLOGY REPORT

DATE OF NOTE: MAY 05, 2017@12:05:55 ENTRY DATE: MAY 05, 2017@12:05:55

AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS:

COMPLETED

$APHDR

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

MEDICAL RECORD | SURGICAL PATHOLOGY

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

PATHOLOGY REPORT Accession No. SP 17 17000

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

$TEXT

Submitted by: Date obtained: May 05, 2017 11:57

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Specimen (Received May 05, 2017 11:57):

TONSIL

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

BRIEF CLINICAL HISTORY:

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

PREOPERATIVE DIAGNOSIS:

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

OPERATIVE FINDINGS:

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

POSTOPERATIVE DIAGNOSIS:

Surgeon/physician: Provider One =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-= - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -



May 05,

2017, 12:05

PM

LR SURGICAL

PATHOLOGY

REPORT

PORTLAND VA

MEDICAL

CENTER

PATHOLOGY REPORT Accession No. SP 17 17000

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

GROSS DESCRIPTION:

Received labled with the patient name, medical record number and "left

tonsil" is a 2.5 x 1.5 x 1.0 cm piece of brown-tan soft tissue. On cut

section there is an ill-defined white-tan 0.7 cm nodule noted.

Representative samples are submitted in one block.

BC 5/5/17

MICROSCOPIC EXAM:

DIAGNOSIS AFTER MICROSCOPIC EXAMINATION:

TONSIL, LEFT, TONSILLECTOMY, TEST CASE:

- MODERATELY DIFFERENTIATED SQUAMOUS CELL CARCINOMA.

- NEOPLASTIC CELLS DIFFUSELY POSITIVE FOR P16.

Comment: The hypothetical H&E stain sections demonstrate an invasive

moderately differentiated nonkeratinizing squamous cell carcinoma.

Immunohistochemical stain p16 shows diffuse strong staining within the

hypothetical malignant cells. This case received intradepartmental

consultation by Provider One who concurs with the above diagnosis.

NOTE: "The Immunohistochemical staining test was developed and its

performance characteristics determined by Pathology & Laboratory

Medicine, PVAMC. It has not been cleared or approved by the U.S. Food

and Drug Administration. The FDA has determined that such clearance or

approval is not necessary. This test is used for clinical purposes. It

should not be regarded as investigational or for research. This

laboratory is certified under the Clinical Laboratory Improvement

Amendments of 1988 (CLIA) as qualified to perform high complexity

clinical laboratory testing."

Slide(s) reviewed and diagnosis rendered by:




/es/ Provider One MD

Signed May 05, 2017@12:05

Performing Laboratory:

Surgical Pathology Report Performed By:

PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131]


$FTR

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

(End of report)

Provider One bgc| Date May 05, 2017

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

MHVTESTVETERAN,ONE A STANDARD FORM 515

ID:666-66-1948 SEX:M DOB:03/01/1948 AGE: 69 LOC:AAALAB ADM:MAY 5,2017 DX:PTSD PCP:

/es/ Provider OneSigned: 05/05/2017 12:05

Jan 05,

2017, 11:15

AM

LR SURGICAL

PATHOLOGY

REPORT

PORTLAND VA

MEDICAL

CENTER

Date Spec taken: Jan 05, 2017 11:15 Pathologist: Provider One Date Spec rec'd: Jan 05, 2017 11:15 Resident:

Date completed: Jan 05, 2017 Accession #: SP 17 113

Submitted by: Provider One Practitioner:0 -------------------------------------------------------------------------------

Specimen:

POLYPS

GROSS DESCRIPTION:

No specimen received. Report only for test patient.

MICROSCOPIC EXAM: (Date Spec taken: Jan 05, 2017 11:15) DIAGNOSIS AFTER MICROSCOPIC EXAMINATION:

POLYPS:

- NO DIAGNOSIS.

- TEST PATIENT REPORT ONLY.

Provider One completed



Diagnosis rendered by:

Provider OneSTAFF PATHOLOGIST

PATHOLOGY AND LAB MED =--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--





Jan 15,

2016, 09:58

AM

LR SURGICAL

PATHOLOGY

REPORT

PORTLAND VA

MEDICAL

CENTER

Date Spec taken: Jan 15, 2016 09:58 Pathologist: Provider One Date Spec rec'd: Jan 15, 2016 09:59 Resident:

Date completed: Jan 15, 2016 Accession #: SP 16 16000 Submitted

by: Practitioner: Provider One -------------------------------------------------------------------------------

Specimen:

BICEPS BRACHII MUSCLE, BIOPSY

*+* SUPPLEMENTARY REPORT HAS BEEN ADDED *+*

*+* REFER TO BOTTOM OF REPORT *+*

Brief Clinical History:

TEST

Preoperative Diagnosis:

TEST

Operative Findings:

TEST

Postoperative Diagnosis:

TEST

GROSS DESCRIPTION:

TEST

MICROSCOPIC EXAM: (Date Spec taken: Jan 15, 2016 09:58) DIAGNOSIS AFTER MICROSCOPIC DESCRIPTION:

TEST PATIENT

MUSCLE BIOPSY:

-MUSCLE TISSUE PRESENT.

DANILOVA,OLGA V completed



-FINAL DIAGNOSIS PENDING OHSU CONSULTATION

Slide(s) reviewed and diagnosis rendered by:

OLGA DANILOVA, M.D.

STAFF PATHOLOGIST

PATHOLOGY AND LAB MED

Supplementary Report:

=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--





Immunizations

This section contains Immunizations on record with VA for the patient. The data comes from all VA treatment facilities. A reaction to an immunization may

be reported in the allergy section.

Immunization Series Date Issued Reaction Comments

VARICELLA May 05, 2017

JAPANESE ENCEPHALITIS IM Jan 05, 2017

TD (ADULT) Jan 05, 2017

TD (ADULT) Jan 15, 2016 NONE this is a test CONTRAINDICATION=DO NOT REPEAT THIS VACCINE.

NOVEL INFLUENZA-H1N1-09, ALL FORMULATIONS Dec 07, 2012 Novartis;#10127605;Feb 2010

TD(ADULT) UNSPECIFIED FORMULATION Dec 07, 2012 1234567

NOVEL INFLUENZA-H1N1-09, ALL FORMULATIONS Oct 01, 2012



PNEUMOCOCCAL POLYSACCHARIDE PPV23 Mar 06, 2011 Inj type: IM, Site:Lt Deltoid

PNEUMOCOCCAL, UNSPECIFIED FORMULATION Mar 06, 2011 Inj type: IM, Site:Lt Deltoid

Encounters

This section contains a list of completed VA Outpatient Encounters for the patient and a list of Encounter Notes, Consult Notes, History & Physical Notes,

and Discharge Summaries for the patient. The data comes from all VA treatment facilities.

The included list of VA Outpatient Encounters displays encounters within the last 18 months and includes a maximum of the 10 most recent encounters.

Follow-up visits related to the VA encounter are not included. The data comes from all VA treatment facilities.

Date/Time Encounter TypeEncounter

DescriptionReason Provider Source

May 08,

2017, 08:00

AM

CARDIOLOGY

STRESS

OUTPT-4A103 VISIT

CARDIAC

STRESS

TEST/ETT

PORTLAND

VA

MEDICAL

CENTER

May 08,

2017, 07:30

AM

ECHOCARDIOGRAM

4A-103 VISITCARDIOLOGY

PORTLAND

VA

MEDICAL

CENTER

May 05,

2017, 12:12

PM

OFFICE/OUTPATIENT

VISIT EST

MENTAL HEALTH

CLINIC - IND

ANKYLOSING SPONDYLITIS OF CERVICAL REGION ICD10 M45.2 with

Provider Comments: Ankylosing spondylitis (SCT 9631008)


VA

MEDICAL

CENTER

May 05,

2017, 12:07

PM

9CANS-O VISITProvider One

PORTLAND

VA

MEDICAL

CENTER



Mar 02,

2017, 08:00

AM

Provider One CLINIC-

AREA A VISIT

TELEPHONE

CASE

MANAGEMENT

PORTLAND

VA

MEDICAL

CENTER

Feb 23,

2017, 08:00

AM

Provider One CLINIC-

AREA A VISIT

TELEPHONE

CASE

MANAGEMENT

PORTLAND

VA

MEDICAL

CENTER

Feb 16,

2017, 08:00

AM

JIM B S FAKE

CLINIC-AREA A VISIT

TELEPHONE

CASE

MANAGEMENT

PORTLAND

VA

MEDICAL

CENTER

Jan 09,

2017, 11:00

AM

CARDIOLOGY

STRESS

OUTPT-4A103 VISIT

CARDIAC

STRESS

TEST/ETT

PORTLAND

VA

MEDICAL

CENTER

Jan 09,

2017, 10:00

AM

ECHOCARDIOGRAM

4A-103 VISITCARDIOLOGY

PORTLAND

VA

MEDICAL

CENTER

Jan 05,

2017, 09:16

AM

C&P PSYCH Provider One-7C515 VISIT

MENTAL HEALTH

CLINIC - IND

MALIGNANT NEOPLASM OF TEMPORAL LOBE ICD10 C71.2 with Provider

Comments: Temporal lobectomy behavior syndrome (SCT 10651001)


VA

MEDICAL

CENTER

The included Encounter Notes are available 3 calendar days after completion and include a maximum of the 5 most recent notes associated to each

Outpatient Encounter. The data comes from all VA treatment facilities.

Date/Time Encounter Note Provider Source

SURGERY CONSULT :

LOCAL TITLE: GEN SURG - CONSULT REQUESTED

STANDARD TITLE: SURGERY CONSULT

DATE OF NOTE: MAY 05, 2017@12:14 ENTRY DATE: MAY 05, 2017@12:14:16



May 05, 2017, 12:14

PM

AUTHOR: Provider One EXP COSIGNER:

URGENCY: STATUS: COMPLETED

I have seen and discussed the patient with my

supervising practitioner, Provider One., and Provider Two.

who is in agreement with the assesment and plan.

/es/ Provider OneCHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 05/05/2017 12:14

Provider One PORTLAND VA MEDICAL

CENTER

May 05, 2017, 12:13

PM

NURSING NOTE :

LOCAL TITLE: MEDICATION OTC ALERT

STANDARD TITLE: NURSING NOTE

DATE OF NOTE: MAY 05, 2017@12:13 ENTRY DATE: MAY 05,

2017@12:13:45 AUTHOR: Provider One EXP COSIGNER:


Your patient MHVTESTVETERAN,ONE A had "Over the Counter" medications entered

into CPRS

today. While entering this information a "medication reaction ALERT" was

relayed to this author. This could have Significant or critical importance.

Please review the patient's active and OTC medications for any concerns you

may have. Items marked with a * indicate potential adverse reactions.

TERAZOSIN, BACTRIM, TRAMADOL, TRIMETHOPRIM, IMIPRAMINE, TETRACYCLINE

PENICILLIN, OXYCODONE, TRIHEXYPHENIDYL

Active Outpatient Medications (including Supplies):

Active Outpatient Medications Status

=========================================================================

1) ALLOPURINOL 300MG TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE

DAY TO LOWER URIC ACID LEVELS IN BLOOD

2) CHOLECALCIFEROL (VIT D3) 400UNIT TAB TAKE 400UNT BY HOLD

MOUTH EVERY DAY

3) FERROUS SULFATE 325MG TAB TAKE ONE TABLET BY MOUTH ACTIVE

TWICE A DAY

4) FOLIC ACID 1MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE

5) LEVOTHYROXINE NA (SYNTHROID) 0.025MG TAB TAKE ONE HOLD


CENTER



TABLET BY MOUTH EVERY DAY ON AN EMPTY STOMACH AND

AT LEAST 4 HOURS BEFORE PRODUCTS CONTAINING


6) VITAMIN A 10000 UNT CAP TAKE 10000UNT BY MOUTH EVERY ACTIVE

DAY DOSES OVER 25,000 UNITS/DAY ARE CONTRAINDICATED

IN PREGNANCY

Active Non-VA Medications Status

=========================================================================

1) Non-VA FISH OIL CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE

2) Non-VA GINKGO BILOBA SMALL AMOUNT MOUTH EVERY DAY ACTIVE

3) Non-VA KAVA CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE

4) Non-VA LISINOPRIL 5MG TAB 2.5MG MOUTH EVERY DAY ACTIVE

5) Non-VA SAW PALMETTO CAP/TAB 1 TAB MOUTH AT BEDTIME ACTIVE

6) Non-VA ST. JOHN'S WART CAP/TAB 1 CAP/TAB MOUTH AT ACTIVE

BEDTIME

12 Total Medications


May 05, 2017, 12:12

PM

MENTAL HEALTH OUTPATIENT NOTE :

LOCAL TITLE: MHD - INDIVIDUAL NOTE

STANDARD TITLE: MENTAL HEALTH OUTPATIENT NOTE




this is only a test



CENTER

C & P EXAMINATION NOTE :

LOCAL TITLE: C&P MENTAL DISORDERS

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: JAN 05, 2017@09:31 ENTRY DATE: JAN 05, 2017@09:32:01



Jan 05, 2017, 09:31

AM

AUTHOR: Provider One EXP COSIGNER:


this is a test



CENTER

The included Consult Notes are from the last 18 months, available 3 calendar days after completion, and include a maximum of the 5 most recent notes.

The data comes from all VA treatment facilities.


May 05, 2017, 12:14 PM

LOCAL TITLE: GEN SURG - CONSULT REQUESTED

STANDARD TITLE: SURGERY CONSULT




I have seen and discussed the patient with my

supervising practitioner, Provider One., and Provider Two.

who is in agreement with the assesment and plan.


Provider One PORTLAND VA MEDICAL CENTER

Jan 05, 2017, 09:30 AM

LOCAL TITLE: CARDIOLOGY - CONSULT

STANDARD TITLE: CARDIOLOGY CONSULT

DATE OF NOTE: JAN 05, 2017@09:30 ENTRY DATE: JAN 05,



this is a test

/es/ Provider One




CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST

Signed: 01/05/2017 09:30

The included H&P Notes are from the last 18 months, available 3 calendar days after completion, and include a maximum of the 2 most recent notes. The

data comes from all VA treatment facilities.


HISTORY & PHYSICAL :

LOCAL TITLE: INPAT - MED - HIST&PHYS

STANDARD TITLE: INTERNAL MEDICINE H & P NOTE




ID: ONE A MHVTESTVETERAN is a 69 year old MALE

PRIMARY CARE PROVIDER: Unknown

ASSOCIATE PROVIDERS:

_______________________________________________________

CC: MHVTESTVETERAN,ONE A presented with a chief complaint of

HISTORY OF PRESENT ILLNESS:

PERTINENT ED COURSE:

PAST MEDICAL HISTORY:

1.

2.

3.

REVIEW OF SYSTEMS:



SOCIAL HISTORY:

NEXT OF KIN/FAMILY CONTACTS:

HABITS:

FAMILY HISTORY:

_______________________________________________________

MEDICATION HISTORY

Active Outpatient Medications

Active Outpatient Medications (including Supplies):

Outpatient Medications Status

========================================================================

=




MOUTH EVERY DAY


TWICE A DAY








IN PREGNANCY

Non-VA Medications Status

========================================================================

=









BEDTIME


--------------------------------------

Active/Pending/Expired Medications:

Active and Recently Expired Outpatient Medications (excluding Supplies):

Active Outpatient Medications Status

========================================================================

=




MOUTH EVERY DAY


TWICE A DAY








IN PREGNANCY

Inactive Outpatient Medications Status

========================================================================

=

1) ACETAMINOPHEN 325MG TAB TAKE 325-650MG BY MOUTH EVERY EXPIRED

4 TO 6 HOURS AS NEEDED *PATIENTS WITHOUT LIVER

DISEASE, MAXIMUM DOSE IS 4 GM/DAY OF ACETAMINOPHEN.

FOR PAIN. THIS IS ONLY A TEST

2) FUROSEMIDE 20MG TAB TAKE ONE-HALF TABLET BY MOUTH EXPIRED

EVERY DAY FOR HEART FAILURE THIS IS ONLY A TEST



May 05, 2017, 12:07

PM

3) SIMVASTATIN 20MG TAB TAKE ONE TABLET BY MOUTH EVERY EXPIRED

EVENING TO LOWER YOUR CHOLESTEROL. AVOID CONSUMING

GRAPEFRUIT PRODUCTS.

4) VITAMIN E 200 UNT CAP TAKE 200UNT BY MOUTH EVERY DAY EXPIRED

Active Non-VA Medications Status

========================================================================

=







BEDTIME


Remote Medications

HDRM - Remote Active Meds

No Active Remote Medications for this patient

RART - Remote ADR

No Remote Allergy/ADR Data available for this patient

--------------------------------------

Medication Reconciliation:

Medications were reviewed with the patient and/or caregiver, and the

above list is accurate, with any exceptions noted.

ALLERGIES:

TERAZOSIN, BACTRIM, TRAMADOL, TRIMETHOPRIM, IMIPRAMINE, TETRACYCLINE

PENICILLIN, OXYCODONE, TRIHEXYPHENIDYL

_______________________________________________________

PHYSICAL:

VITALS SIGNS


CENTER



Blood pressure: 82/40 (01/05/2017 06:46)

Pulse: 120 (01/05/2017 06:46)

Temperature: 102.2 F [39.0 C] (01/05/2017 06:46)

Respirations: 22 (01/05/2017 06:46)

Weight: 180 lb [81.8 kg] (01/05/2017 06:43)

Height: 72 in [182.9 cm] (01/05/2017 06:43)

EXAM:

General:

HEENT:

Neck:

Chest:

Cardiac:

Abdomen:

Back/Extrem:

GU/Rectal:

Neuro:

Skin:

_________________________________________________

LABORATORY DATA:

WBC canc 01/05/2017 10:00

HCT canc 01/05/2017 10:00

MCV canc 01/05/2017 10:00

AUTO DIFF 01/05/2017 10:00

LY% 29.6

LY# 2.5

NE# 5.0

NE% 59.7

MO# 0.7

MO% 7.8

EO# 0.1

BA# 0.1

EO% 1.8

BA% 1.1

SODIUM 145 H 01/05/2017 10:00



POTASSIUM 3.9 01/05/2017 10:00

CHLORIDE 121 H 01/05/2017 10:00

CO2 32

UREA NITROGEN 20 01/05/2017 10:00

CREATININE 2.0 H 01/05/2017 10:00

Cardiac Enzymes last 72 hours:

No Results last 72 hours

_______________________________________________________

IMAGING:

OTHER DATA:

______________________________________________

IMPRESSION:

_______________________________________________________

ASSESMENT AND PLAN:

PROBLEM 1:

PLAN:

PROBLEM 2:

PLAN:

PROBLEM 3:

PLAN:

PROPHYLAXIS ISSUES:

_______________________________________________________

CODE STATUS:

The patient will be staffed with Provider One. within 24 hours.




Jan 05, 2017, 12:38

PM

HISTORY & PHYSICAL :

LOCAL TITLE: ORTHOPEDICS - HISTORY & PHYSICAL

STANDARD TITLE: ORTHOPEDIC SURGERY H & P NOTE

DATE OF NOTE: JAN 05, 2017@12:38 ENTRY DATE: JAN 05,



HISTORY AND PHYSICAL



CENTER

The included Discharge Summary Notes are from the last 18 months, available 3 calendar days after completion, and include a maximum of the 2 most

recent notes. The data comes from all VA treatment facilities.


DISCHARGE SUMMARY :

LOCAL TITLE: Discharge Summary

STANDARD TITLE: DISCHARGE SUMMARY

DICT DATE: MAY 05, 2017@12:05 ENTRY DATE: MAY 05,

2017@12:06:05 DICTATED BY: Provider One ATTENDING: Provider One URGENCY: routine STATUS: COMPLETED

ATTENDING PHYSICIAN:

PRIMARY CARE PROVIDER AND FACILIITY:

PRINCIPAL DIAGNOSIS:

OTHER DIAGNOSES TREATED OR IMPACTING TREATMENT THIS ADMISSION:



May 05, 2017

PROCEDURES PERFORMED AT THIS HOSPITAL DURING CURRENT ADMISSION:

SUMMARY:

(ABBREVIATED HPI, PE, AND PERTINENT LABS)

HOSPITAL COURSE:

FUNCTIONAL STATUS:

(MAY INCLUDE ACTIVITY LEVEL, WORK RESTRICTIONS, OR DIET)

DISCHARGE MEDICATIONS:

(INDICATE ADDITIONS OR CHANGES WITH AN ASTERISK)

MEDICATIONS THAT HAVE BEEN DISCONTINUED:

CLINICAL ISSUES REQUIRING FOLLOW UP DURING PC PHONE APT:

1.

2.

3.

ADDITIONAL FOLLOW UP APPOINTMENTS:

SPECIALTY EXPECTED DATE SCHEDULED(Y/N) POINT OF CONTACT

1.

2.

3.

FOLLOW UP LABS INCLUDING PATHOLOGY & MICROBIOLOGY:

TEST ORDERED(Y/N) EXPECTED DATE IF NOT ORDERED

1.

2.




3.

FOLLOW UP IMAGING AND PROCEDURES:

PROCEDURE ORDERED(Y/N) EXPECTED DATE IF NOT ORDERED

1.

2.

3.


DISCHARGE SUMMARY :

LOCAL TITLE: Discharge Summary

STANDARD TITLE: DISCHARGE SUMMARY

DICT DATE: JAN 05, 2017@12:36 ENTRY DATE: JAN 05,

2017@12:37:04 DICTATED BY: Provider One

ATTENDING: Provider OneURGENCY: routine STATUS: COMPLETED

ATTENDING PHYSICIAN:

PRIMARY CARE PROVIDER AND FACILIITY:

PRINCIPAL DIAGNOSIS:

OTHER DIAGNOSES TREATED OR IMPACTING TREATMENT THIS ADMISSION:

PROCEDURES PERFORMED AT THIS HOSPITAL DURING CURRENT ADMISSION:

SUMMARY:

(ABBREVIATED HPI, PE, AND PERTINENT LABS)

HOSPITAL COURSE:

FUNCTIONAL STATUS:



Jan 05, 2017

(MAY INCLUDE ACTIVITY LEVEL, WORK RESTRICTIONS, OR DIET)

DISCHARGE MEDICATIONS:

(INDICATE ADDITIONS OR CHANGES WITH AN ASTERISK)

MEDICATIONS THAT HAVE BEEN DISCONTINUED:

CLINICAL ISSUES REQUIRING FOLLOW UP DURING PC PHONE APT:

1.

2.

3.

ADDITIONAL FOLLOW UP APPOINTMENTS:

SPECIALTY EXPECTED DATE SCHEDULED(Y/N) POINT OF CONTACT

1.

2.

3.

FOLLOW UP LABS INCLUDING PATHOLOGY & MICROBIOLOGY:

TEST ORDERED(Y/N) EXPECTED DATE IF NOT ORDERED

1.

2.

3.

FOLLOW UP IMAGING AND PROCEDURES:

PROCEDURE ORDERED(Y/N) EXPECTED DATE IF NOT ORDERED

1.

2.

3.

/es/Provider One




CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST

Signed: 01/05/2017 12:37

The included list of additional Discharge Summary Note Titles is from the last 18 months. The data comes from all VA treatment facilities.

Date/Time Encounter Note Title Provider Source

Jan 05, 2017 DISCHARGE SUMMARY Provider One PORTLAND VA MEDICAL CENTER

Procedures

No Data Provided for This Section

Plan of Care


Functional Status


Family History

No data provided for this section.

Social History

This section displays the smoking status on record at all VA facilities for the patient.



Contact Information

Emergency contact ORLEN ANDERSON

Primary Home:

Date/Time Smoking Status Comment Facility

Dec 07, 2012, 11:55 AM CURRENT TOBACCO USER PORTLAND VA MEDICAL CENTER

Dec 07, 2012, 11:55 AM WILLING TO QUIT: NO PORTLAND VA MEDICAL CENTER

Insurance Providers


Advance Directive

This section contains ALL of a patient's completed or amended VA Advance and Rescinded Directives. Entries below indicate that a directive exists for the

patient, but an actual copy is not included with this document.

Date Advance Directives Provider Source

Jan 24, 2013 ADVANCE DIRECTIVE Provider One PORTLAND VA MEDICAL CENTER

Healthcare Providers


Contact Information



403 E. STEWART

COLUMBUS, OHIO 43232

Tel: +1-614-444-1952

Next of kin ORLEN ANDERSON

Primary Home:

403 E. STEWART

COLUMBUS, OHIO 43232

Tel: +1-614-444-1952



Documents

Department of Veterans Affairs Prepared ONE … · Jan 05, 2017 Provider One PORTLAND VA MEDICAL CENTER ST. JOHN'S WORT CAP/TAB Non-VA TAKE 1 CAP/TAB BY MOUTH AT BEDTIME Non-VA Documented