Continuity of Care Document (C-CDA) 1122 Mystical Rt 3 Beaverton OR 97005 US Jones Isabella NEXTGEN Medical Practice (Horsham) 795 Horsham Road Horsham PA 19044 1002 Healthcare Dr Beaverton OR 97005 Admin NextGen NEXTGEN Medical Practice (Horsham) 795 Horsham Road Horsham PA 19044 NEXTGEN Medical Practice (Horsham) 795 Horsham Road Horsham PA 19044 US 1002 Healthcare Dr Beaverton OR 97005 US Henry Seven
Allergies, Adverse Reactions, Alerts
Substance Reaction Severity Status
Codeine Shortness of Breath Unknown Active
aspirin Hives Unknown Active
PENICILLIN G BENZATHINE Hives Unknown Active
Codeine aspirin PENICILLIN G BENZATHINE
Medications
Medication Instructions Dosage Effective Dates (start - stop) Status Comments
metoprolol tartrate 25 mg tablet take 1 tablet by oral route every day 25 MG Feb-12-2013 - Active
clarithromycin 500 mg tablet take 1 tablet by oral route 2 times daily for 7 days Aug-06-2012 - Active
albuterol sulfate HFA 90 mcg/actuation Aerosol Inhaler inhale 2 puff by inhalation route every 4 - 6 hours as needed as needed for Wheezing 0 Apr-02-2012 - Apr-02-2013 Active
albuterol sulfate HFA 90 mcg/actuation Aerosol Inhaler inhale 2 puffs once as needed Aug-06-2012 - Aug-06-2012 No Longer Active Administered in office
METOPROLOL TARTRATE 1002 Healthcare Dr Beaverton OR 97005 Getwell James NEXTGEN Medical Practice (Horsham) 795 Horsham Road Horsham PA 19044 CLARITHROMYCIN 1002 Healthcare Dr Beaverton OR 97005 Getwell James NEXTGEN Medical Practice (Horsham) 795 Horsham Road Horsham PA 19044 ALBUTEROL SULFATE HFA 1002 Healthcare Dr Beaverton OR 97005 Seven Henry NEXTGEN Medical Practice (Horsham) 795 Horsham Road Horsham PA 19044 ALBUTEROL SULFATE HFA 1002 Healthcare Dr Beaverton OR 97005 Getwell James NEXTGEN Medical Practice (Horsham) 795 Horsham Road Horsham PA 19044
Problems
Condition Effective Dates (start - stop) Clinical Status
Community acquired pneumonia Jan-25-2013 - Active
Asthma Jan-25-2013 - Controlled
Hypoxemia Jan-25-2013 - Mild
Procedures
Procedure Date
Immunization admin, 1 vaccine Jan-25-2013
Immunization admin, 1 vaccine Jan-25-2013
Immunization admin, 1 vaccine Jan-25-2013
Immunization admin, 1 vaccine Jan-25-2013
CHEST COMPRESSION GEN SYSTEM Aug-06-2012
Results
Test Name Date and Time Measure Units Reference Range Abnormal Flag Comments
Unknown
Advance Directives
Directive Yes / No Effective Date
Resuscitation Yes 8/6/2012
Life Support Yes 8/6/2012
Intubation Yes 8/6/2012
Antibiotics Yes 8/6/2012
IV Fluid Support Yes 8/6/2012
Tube Feed Yes 8/6/2012
CPR Yes 8/6/2012
Other Directive Yes 8/6/2012
WARNING:The information contained in this section is historical and is provided for information only and does not constitute a legal document or any assurance that the information is still accurate. Please verify the information with the holder of the legal document before using it for clinical purposes.
Encounters
Encounter Practice Location Reason(s) For Visit Diagnoses Date
Patient Visit NEXTGEN Medical Practice (Horsham), 795 Horsham Road, Horsham, PA, 19044 tel:+1-2156577010 Get Well Clinic Mild Fever, 2 days Chills, 2 days Cough productive of greenish sputum, 2 days Hypoxemia Community acquired pneumonia Asthma Aug-06-2012
1002 Healthcare Dr Beaverton OR 97005 Seven Henry L NEXTGEN Medical Practice (Horsham) 795 Horsham Road Horsham PA 19044 1002 Healthcare Dr Beaverton OR 97005 Get Well Clinic
Family History
Family Member Diagnosis Age At Onset Status
Unknown
Immunizations
Vaccine Date Status Comments
Pneumo (2 yrs or older) (PPV23) Aug-06-2012 completed - Completed reason: New
Influenza Virus vaccine Sep-10-2011 completed - Completed reason: New
Influenza Virus vaccine Nov-01-2010 completed - Completed reason: New
Td (7 yrs or older) Jan-04-2007 completed - Completed reason: New
90390 GlaxoSmithKline Villalon RN May 839208 Vaccine Company Villalon RN May 839208 Vaccine Company Villalon RN May 90289 GlaxoSmithKline Villalon RN May
Payers
Payer name Insurance type Covered party ID Authorization(s)
Unknown
Social History
Description Quantity Date
Smoking Status Current every day smoker 1992
Vital Signs
Date / Time: Height Weight BMI Pulse Rate Blood Pressure Temperature Respiratory Rate Body Surface Area Head Circumference
Aug-06-2012/12:13:00 69.69 in 194.01 lbs 28.08 135/92 mm[Hg]
Reason For Visit *** Most recent encounter only, dated '08/06/2012 10:59'. *** Mild Fever, 2 days Chills, 2 days Cough productive of greenish sputum, 2 days
Reason For Referral
Reason For Referral
Unknown
Plan Of Care
Date Type Action Status
Feb-12-2013 Goal Colonoscopy. Due on Sep-22-2012 due
Feb-15-2013 Referral referred to Penny Puffer, MD Pulmonary Disease For consultation, 555-555-1049, 1047 Healthcare Dr, Portland, OR 97005 -today 08/20/2012 (related to Community acquired pneumonia) ordered
02/20/2013 09:00 Appointment Jones, Isabella --- Dr. Henry Seven, 1007 Healthcare Dr., Portland, OR 99123 On Test Date + 3 Weeks BOOKED
02/19/2013 08:10 Appointment Jones, Isabella BOOKED
Aug-06-2012 Patient Education Stopping Smoking: After Your Visit completed
Feb-18-2013 Future Order: Lab Order Sputum Culture (Sputum Clt), Collected on: Aug-06-2012 Ordered
Feb-18-2013 Future Order: Radiology Order Chest X-ray (CXR), Scheduled on: Aug-13-2012 Ordered
Feb-18-2013 Future Order: Radiology Order Chest x-ray, two views (71020), Body Site: Lower Respiratory Tract Strcture, Collected on: Aug-06-2012 Ordered
Feb-18-2013 Future Order: Lab Order HGB (NG005041), Scheduled on: Aug-13-2012 Ordered
History Of Present Illness Mild Fever, 2 days Chills, 2 days Cough productive of greenish sputum, 2 days
Functional Status
Functional / Cognitive Date Status
Cognitive Aug-06-2012 No impairment
Functional Aug-06-2012 Active
Medications Administered
Medication Instructions Dosage Effective Dates (start - stop) Status Comments
albuterol sulfate HFA 90 mcg/actuation Aerosol Inhaler inhale 2 puffs once as needed Aug-06-2012 - Aug-06-2012 No Longer Active Administered in office
ALBUTEROL SULFATE HFA 1002 Healthcare Dr Beaverton OR 97005 Getwell James NEXTGEN Medical Practice (Horsham) 795 Horsham Road Horsham PA 19044
Instructions
Date Instruction Additional Information
Feb-12-2013 Patient may continue to experience low grade fever and chills. Related to Community acquired pneumonia
Feb-12-2013 Return to clinic or call 911 if you experience chest pain, shortness of breath, high fevers, or intractable vomiting/diarrhea Related to Community acquired pneumonia