Community Health and Hospitals: Health Summary 4315 Meadowbrook Mall Road Los Angeles CA 90017 US Carole Jacobs 1418 Kelley Road Biloxi MS 39530 US Mr. Michael Wilson Pembroke KY 42266 US Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US 1001 Village Avenue Portland OR 99123 US Henry Seven 1001 Village Avenue Portland OR 99123 US Henry Seven Frank Jones Community Health and Hospitals 1002 Healthcare Drive Portland OR 99123 US Henry Seven Community Health and Hospitals 17 Daws Rd. Beaverton OR 97867 US Mrs. Martha Jones Primary Care Provider 1001 Village Avenue Portland OR 99123 US Henry Seven MD Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US
Allergies, Adverse Reactions & Alerts
Group Description Code System Code Code Description Severity Susceptibility Date and Time Status
Bakers Yeast RxNorm 892677 Baker's yeast allergenic extract 100 MG/ML Injectable Solution Moderate Susceptible 03-31-2010 10:00:00 Active
Bakers Yeast + Baker's yeast allergenic extract 100 MG/ML Injectable Solution Bakers Yeast + Baker's yeast allergenic extract 100 MG/ML Injectable Solution
Encounters
Group Description Code System Code Code Description Date and Time Status
Encounter Outpatient CPT 99213 Office/outpatient visit, est 03-31-2010 10:00:00 Performed
ICD-9-CM V70.0 Routine general medical examination at a health care facility
Encounter Ophthalmological Services CPT 92012 Eye exam established pat 04-20-2010 10:00:00 Performed
Encounter Ob/Gyn ICD-9-CM V72.31 Routine gynecological examination 05-16-2010 10:00:00 Performed
Encounter Outpatient Including Orthopedics an CPT 98940 Chiropractic manipulation 06-04-2010 10:00:00 Performed
Encounter Ophthalmological Services CPT 92012 Eye exam established pat 08-16-2010 10:00:00 Performed
Encounter Outpatient CPT 99213 Office/outpatient visit, est 12-07-2010 10:00:00 Performed
ICD-9-CM V70.0 Routine general medical examination at a health care facility
Encounter Outpatient + Encounter Outpatient Encounter Ophthalmological Services + Encounter Ophthalmological Services Encounter Ob/Gyn + Encounter Ob/Gyn Encounter Outpatient Including Orthopedics an + Encounter Outpatient Including Orthopedics an Encounter Ophthalmological Services + Encounter Ophthalmological Services Encounter Outpatient + Encounter Outpatient
Immunizations
Group Description Code System Code Code Description Date and Time Status
Influenza Vaccine CVX 135 Influenza, high dose seasonal 12-07-2010 10:00:00 Completed
Pneumococcal Vaccine ages 2 and older CVX 33 pneumococcal polysaccharide PPV23 12-07-2010 10:00:00 Completed
Influenza Vaccine + Influenza Vaccine 101 Maple Street Washington DC 20009 United States Jim Smith Good Hospital 101 Maple Street Washington DC 20009 United States Pneumococcal Vaccine ages 2 and older + Pneumococcal Vaccine ages 2 and older 101 Maple Street Washington DC 20009 United States Jim Smith Good Hospital 101 Maple Street Washington DC 20009 United States
Medications
Group Description Code System Code Code Description Date and Time Status
Antidiabetic combinations RxNorm 861748 Glyburide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet 05-18-2009 10:00:00 Active
Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US Antidiabetic combinations + Glyburide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet Antidiabetic combinations
Problems
Group Description Code System Code Code Description Date and Time Status
Diabetes SNOMED-CT 44054006 Diabetes mellitus type 2 03-31-2010 10:00:00 Active
ICD-10-CM E11.9 Type 2 diabetes mellitus without complications
ICD-9-CM 250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Diabetic Retinopathy SNOMED-CT 312904009 Moderate nonproliferative diabetic retinopathy 04-20-2010 10:00:00 Active
ICD-10-CM E13.33 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy
ICD-9-CM 362.05 Moderate nonproliferative diabetic retinopathy
low back pain SNOMED-CT 279039007 Low back pain 06-04-2010 10:00:00 Active
ICD-10-CM M54.9 Dorsalgia, unspecified
ICD-9-CM 724.2 Lumbago
Procedures
Group Description Code System Code Code Description Date and Time Status
Foot Exam SNOMED-CT 401191002 Diabetic foot examination 03-31-2010 10:00:00 Performed
Macular or Fundus Exam SNOMED-CT 312905005 Severe nonproliferative diabetic retinopathy 04-10-2010 10:00:00 Performed
SNOMED-CT 37231002 Macular retinal edema
SNOMED-CT 410455004 Slit lamp fundus examination
Eye Exam CPT 92012 Eye exam established pat 04-20-2010 10:00:00 Performed
HCPCS S0621 Routine ophthalmological exa
ICD-9-CM 95.03 Extended ophthalmologic work-up
SNOMED-CT 36228007 Ophthalmic examination and evaluation
Macular or Fundus Exam SNOMED-CT 312905005 Severe nonproliferative diabetic retinopathy 04-20-2010 10:00:00 Performed
SNOMED-CT 37231002 Macular retinal edema
SNOMED-CT 410455004 Slit lamp fundus examination
Foot Exam SNOMED-CT 401191002 Diabetic foot examination 05-16-2010 10:00:00 Performed
Breast Cancer Screening CPT 77057 Mammogram, screening 09-23-2010 10:00:00 Performed
HCPCS G0202 Screeningmammographydigital
ICD-10-CM Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
ICD-9-CM V76.12 Other screening mammogram
SNOMED-CT 24623002 Screening mammography
Foot Exam SNOMED-CT 401191002 Diabetic foot examination 12-07-2010 10:00:00 Performed
Foot Exam + Diabetic foot examination Macular or Fundus Exam + Severe nonproliferative diabetic retinopathy Eye Exam + Eye exam established pat Macular or Fundus Exam + Severe nonproliferative diabetic retinopathy Foot Exam + Diabetic foot examination Breast Cancer Screening + Mammogram, screening Foot Exam + Diabetic foot examination
Results
Group Description Code System Code Code Description Value Unit Reference Range Date and Time Status
Chlamydia Screening LOINC 31777-6 C trach Ag XXX Ql negative NA 06-18-2007 10:00:00 Completed
CPT 87270 Chlamydia trachomatis ag if
SNOMED-CT 121953005 Measurement of Chlamydia pneumoniae antibody
Pap Test LOINC 10524-7 Cyto Cervix normal NA 06-18-2007 10:00:00 Completed
CPT 88174 Cytopath, c/v auto, in fluid
HCPCS G0147 Scr c/v cyto, automated sys
ICD-10-CM Z12.4 Encounter for screening for malignant neoplasm of cervix
ICD-9-CM V72.32 Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear
SNOMED-CT 440623000 Microscopic examination of cervical Papanicolaou smear
HbA1c test LOINC 4548-4 Hgb A1c MFr Bld 7.4 % 4-5.6% 03-31-2010 10:00:00 Completed
CPT 83036 Glycated hemoglobin test
SNOMED-CT 43396009 Hemoglobin A1c measurement
High Density Lipoprotein (HDL) LOINC 14646-4 HDLc SerPl-sCnc 45 mg/dL >=40 mg/dL 03-31-2010 10:00:00 Completed
CPT 83701 Lipoprotein bld, hr fraction
SNOMED-CT 28036006 High density lipoprotein cholesterol measurement
Low Density Lipoprotein (LDL) LOINC 2089-1 LDLc SerPl-mCnc 105 mg/dL <130 mg/dL (calc) 03-31-2010 10:00:00 Completed
CPT 83721 Assay of blood lipoprotein
SNOMED-CT 113079009 Low density lipoprotein cholesterol measurement
Total Cholesterol LOINC 2093-3 Cholest SerPl-mCnc 170 mg/dL 125-200 mg/dL 03-31-2010 10:00:00 Completed
CPT 82465 Assay, bld/serum cholesterol
SNOMED-CT 121868005 Total cholesterol measurement
Triglycerides LOINC 12951-0 Trigl SerPl Calc-mCnc 100 mg/dL 10-39 years: 55-110 mg/dL | 40-59 years: 70-150 mg/dL | >60 years: 80-150 mg/dL | Therapeutic Target: <100 mg/dL 03-31-2010 10:00:00 Completed
CPT 84478 Assay of triglycerides
SNOMED-CT 14740000 Triglycerides measurement
Chlamydia Screening LOINC 31777-6 C trach Ag XXX Ql negative NA 05-16-2010 10:00:00 Completed
CPT 87270 Chlamydia trachomatis ag if
SNOMED-CT 121953005 Measurement of Chlamydia pneumoniae antibody
Pap Test LOINC 10524-7 Cyto Cervix normal NA 05-16-2010 10:00:00 Completed
CPT 88174 Cytopath, c/v auto, in fluid
HCPCS G0147 Scr c/v cyto, automated sys
ICD-10-CM Z12.4 Encounter for screening for malignant neoplasm of cervix
ICD-9-CM V72.32 Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear
SNOMED-CT 440623000 Microscopic examination of cervical Papanicolaou smear
HbA1c test LOINC 4548-4 Hgb A1c MFr Bld 6.9 % 4-5.6% 06-15-2010 10:00:00 Completed
CPT 83036 Glycated hemoglobin test
SNOMED-CT 43396009 Hemoglobin A1c measurement
HbA1c test LOINC 4548-4 Hgb A1c MFr Bld 6.6 % 4-5.6% 09-08-2010 10:00:00 Completed
CPT 83036 Glycated hemoglobin test
SNOMED-CT 43396009 Hemoglobin A1c measurement
HbA1c test LOINC 4548-4 Hgb A1c MFr Bld 7.4 % 4-5.6% 12-17-2010 10:00:00 Completed
CPT 83036 Glycated hemoglobin test
SNOMED-CT 43396009 Hemoglobin A1c measurement
NA NA 4-5.6% >=40 mg/dL <130 mg/dL (calc) 125-200 mg/dL 10-39 years: 55-110 mg/dL | 40-59 years: 70-150 mg/dL | >60 years: 80-150 mg/dL | Therapeutic Target: <100 mg/dL NA NA 4-5.6% 4-5.6% 4-5.6%
Social History
Group Description Code System Code Code Description Date and Time Status
Tobacco Use SNOMED-CT 266919005 Never smoker (Never Smoked) 03-31-2010 10:00:00 Active
SNOMED-CT 449868002 Current every day smoker
STD History SNOMED-CT 8098009 Sexually transmitted infectious disease 05-16-2010 10:00:00 Active
ICD-10-CM A64 Unspecified sexually transmitted disease
ICD-9-CM 099.9 Venereal disease, unspecified
Tobacco Use + Never smoker (Never Smoked) STD History + Sexually transmitted infectious disease
Vital Signs
Group Description Code System Code Code Description Value Unit Date and Time Status
BMI LOINC 39156-5 BMI 30.1 kg/m2 03-31-2010 10:00:00 Finding
Diastolic Blood Pressure LOINC 8462-4 BP Diastolic 80 mm[Hg] 03-31-2010 10:00:00 Finding
Systolic Blood Pressure LOINC 8480-6 BP Systolic 126 mm[Hg] 03-31-2010 10:00:00 Finding
BMI LOINC 39156-5 BMI 30.1 kg/m2 05-16-2010 10:00:00 Finding
Diastolic Blood Pressure LOINC 8462-4 BP Diastolic 72 mm[Hg] 05-16-2010 10:00:00 Finding
Systolic Blood Pressure LOINC 8480-6 BP Systolic 118 mm[Hg] 05-16-2010 10:00:00 Finding
BMI LOINC 39156-5 BMI 29.2 kg/m2 12-07-2010 10:00:00 Finding
Diastolic Blood Pressure LOINC 8462-4 BP Diastolic 78 mm[Hg] 12-07-2010 10:00:00 Finding
Systolic Blood Pressure LOINC 8480-6 BP Systolic 130 mm[Hg] 12-07-2010 10:00:00 Finding