Generated Narrative: Composition BSJ2-TOCComposition2 Language: en-US Profile: Transition of Care Composition identifier: http://example.org/GoodHealthClinic/id/76053988-543c-4681-9a90-2f2eb9a7836c-CCDA-CCD status: Final type: Physician Discharge summary date: 2024-05-10 08:49:58-0400 author: Practitioner Judy Salas title: Transitions of Care Document for Betsy Smith-Johnson custodian: Organization Motown Home Health Grand Rapids
Transitions of Care Document for Betsy Smith-Johnson
Advance directives for Betsy Smith-Johnson
List of allergies for Betsy Smith-Johnson
Allergies for Betsy Smith-Johnson
Behavioral health information for Betsy Smith-Johnson
Functional status of Betsy Smith-Johnson
List of immunizations for Betsy Smith-Johnson
Discharge instructions for Betsy Smith-Johnson
List of medical equipment needed by Betsy Smith-Johnson
List of medications prescribed for Betsy Smith-Johnson
Discharge care plan for Betsy Smith-Johnson
List of problem conditions and observations for Betsy Smith-Johnson
List of procedures prescribed for Betsy Smith-Johnson
Reason for referring Betsy Smith-Johnson
List of test results for Betsy Smith-Johnson
Social history for Betsy Smith-Johnson
Vital signs for Betsy Smith-Johnson
Generated Narrative: Patient Example-Smith-Johnson-Patient2 Last updated: 2021-03-29 14:25:34-0500; Language: en-US Profile: US Core Patient Profile version: 8.0.1 Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26) Active: true Marital Status: unknown Other Id: Medical Record Number/1032702A (use: usual, ) Contact Detail ph: 555-555-5555(Home) ph: (410) 444-5555 111 Maple Ct, Grand Rapids, MI 49503 Language: English (preferred) son: Charles Johnson 111 Maple Ct, Grand Rapids, MI 49503 ph: (210) 222-3333 daughter: Debra Johnson 333 W. Camden St., Baltimore, MD 21201 ph: (410) 444-5555 <td style="background-color: #f3f5da" title="Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The race codes used to represent these concepts are based upon the [Race & Ethnicity - CDC (CDCREC)](https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.113883.6.238) which includes over 900 concepts for representing race and ethnicity of which 921 reference race. The race concepts are grouped by and pre-mapped to the 5 OMB race categories:#xA;#xA; - American Indian or Alaska Native#xA; - Asian#xA; - Black or African American#xA; - Native Hawaiian or Other Pacific Islander#xA; - White.">US Core Race Extension: ombCategory: Race & Ethnicity - CDC: 2106-3 (White) text: White
Generated Narrative: Condition BSJ2-DepressionDiagnosis Profile: US Core Condition Encounter Diagnosis Profile version: 8.0.1 Condition Asserted Date: 2005-02 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Depressive disorder (disorder) bodySite: Brain structure (body structure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)
Generated Narrative: Condition BSJ2-DiabetesDiagnosis Profile: US Core Condition Encounter Diagnosis Profile version: 8.0.1 Condition Asserted Date: 2017-06 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Diabetes mellitus type 2 in nonobese (disorder) bodySite: Structure of endocrine system (body structure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26) onset: 2017-06 recordedDate: 2017-06-05 asserter: PractitionerRole Internal Medicine Physician
Diabetes mellitus type 2 in nonobese (disorder)
Structure of endocrine system (body structure)
Generated Narrative: Condition BSJ2-HyperlipidemiaDiagnosis Profile: US Core Condition Encounter Diagnosis Profile version: 8.0.1 Condition Asserted Date: 2018-06 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Hyperlipidemia (disorder) bodySite: Structure of cardiovascular system (body structure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26) asserter: PractitionerRole Internal Medicine Physician
Structure of cardiovascular system (body structure)
Generated Narrative: Condition BSJ2-ProblemList-PressureInjury Profile: US Core Condition Problems and Health Concerns Profile version: 8.0.1 clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item code: Pressure injury of left hip stage II (disorder) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26) recordedDate: 2024-04-27 15:40:00-0400 asserter: Practitioner Judy Salas
Pressure injury of left hip stage II (disorder)
Generated Narrative: Observation BSJ2-ADL-Mobility Profile: US Core Simple Observation Profile version: 8.0.1 Event Location: Location Motown Home Health Facility status: Final category: Functional Status code: Need help getting out of bed, showered, or dressed subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26) effective: 2024-05-16 14:30:00-0400 performer: PractitionerRole Occupational Therapist value: Yes
Need help getting out of bed, showered, or dressed
Generated Narrative: Device BSJ2-Device-WoundPump DeviceNames - Name Type * Wound Pump User Friendly name type: Negative-pressure wound therapy system pump (physical object)
Negative-pressure wound therapy system pump (physical object)
Generated Narrative: Device BSJ2-Device-Wheelchair DeviceNames - Name Type * Wheelchair User Friendly name type: Wheelchair device (physical object)
Generated Narrative: List BSJ2-SMPMedList Profile: Standardized Medication Profile - Medication List Home Health Medication List Date: 2024-08-11 Mode: Working List Status: Current Code: Patient generated medication list [Identifier] Episode Pharmacy Subject: Betsy Smith-JohnsonSource: Items Date atorvastatin 40 MG Oral Tablet 2024-08-11 sertraline 25 MG Oral Tablet 2024-08-11 empagliflozin 10 MG Oral Tablet [Jardiance] 2024-08-11
Patient generated medication list [Identifier] Episode Pharmacy
empagliflozin 10 MG Oral Tablet [Jardiance]
Generated Narrative: MedicationStatement BSJ2-SMPMedStmt1 Profile: Standardized Medication Profile - MedicationStatement basedOn: MedicationRequest: status = active; intent = order; medication[x] = atorvastatin 40 MG Oral Tablet; authoredOn = 2024-08-11; reasonCode = Hyperlipidemia status: active medication: atorvastatin 40 MG Oral Tablet subject: Betsy Smith-Johnson dateAsserted: 2024-08-11 informationSource: Judy Salas, DNP reasonCode: Hyperlipidemia reasonReference: Condition Hyperlipidemia (disorder) Dosages - Sequence Text * 1 po nightly
Generated Narrative: MedicationStatement BSJ2-SMPMedStmt4 Profile: Standardized Medication Profile - MedicationStatement basedOn: MedicationRequest: status = active; intent = order; medication[x] = sertraline 25 MG Oral Tablet; authoredOn = 2024-08-11; reasonCode = Depressive disorder (disorder) status: active medication: sertraline 25 MG Oral Tablet subject: Betsy Smith-Johnson dateAsserted: 2024-08-11 informationSource: Judy Salas, DNP reasonCode: Depressive disorder (disorder) reasonReference: Condition Depressive disorder (disorder) Dosages - Sequence Text * 1 po once daily
Generated Narrative: MedicationStatement BSJ2-SMPMedStmt9 Profile: Standardized Medication Profile - MedicationStatement basedOn: MedicationRequest: status = active; intent = order; medication[x] = empagliflozin 10 MG Oral Tablet [Jardiance]; authoredOn = 2024-08-11; reasonCode = Diabetes mellitus type 2 in nonobese (disorder) status: active medication: empagliflozin 10 MG Oral Tablet [Jardiance] subject: Betsy Smith-Johnson dateAsserted: 2024-08-11 informationSource: Judy Salas, DNP reasonCode: Diabetes mellitus type 2 in nonobese (disorder) reasonReference: Condition Diabetes mellitus type 2 in nonobese (disorder) Dosages - Sequence Text * 1 po nightly
Generated Narrative: MedicationRequest BSJ2-SMPMedReq1 Profile: US Core MedicationRequest Profile status: Active intent: Order medication: atorvastatin 40 MG Oral Tablet subject: Betsy Smith-Johnson authoredOn: 2024-08-11 requester: Judy Salas, DNP reasonCode: Hyperlipidemia DosageInstructions - Sequence Text * 1 po nightly
Generated Narrative: MedicationRequest BSJ2-SMPMedReq4 Profile: US Core MedicationRequest Profile status: Active intent: Order medication: sertraline 25 MG Oral Tablet subject: Betsy Smith-Johnson authoredOn: 2024-08-11 requester: Judy Salas, DNP reasonCode: Depressive disorder (disorder) reasonReference: Condition Depressive disorder (disorder) DosageInstructions - Sequence Text * 1 po once daily
Generated Narrative: MedicationRequest BSJ2-SMPMedReq9 Profile: US Core MedicationRequest Profile status: Active intent: Order medication: empagliflozin 10 MG Oral Tablet [Jardiance] subject: Betsy Smith-Johnson authoredOn: 2024-08-11 requester: Judy Salas, DNP reasonCode: Diabetes mellitus type 2 in nonobese (disorder) reasonReference: Condition Diabetes mellitus type 2 in nonobese (disorder) DosageInstructions - Sequence Text * 1 once daily
Generated Narrative: CarePlan BSJ2-DischargeCarePlan Profile: US Core CarePlan Profile version: 8.0.1 status: Active intent: Plan category: Assessment and Plan of Treatment subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH16) activity reference: ServiceRequest Follow-up visit (procedure) activity reference: ServiceRequest/BSJ2-SNFDischargeDietSalt activity reference: ServiceRequest/BSJ2-SNFDischargeLabOrderBMP activity reference: ServiceRequest/BSJ2-SNFDischargeLabOrderCBC activity reference: ServiceRequest/BSJ2-SNFDischargePTRefer
Generated Narrative: ServiceRequest BSJ2-PCPFollowUp Profile: US Core ServiceRequest Profile version: 8.0.1 status: Active intent: Order category: Evaluation procedure (procedure) priority: Routine code: Follow-up visit (procedure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26) occurrence: 2024-05-28 authoredOn: 2024-05-18 requester: PractitionerRole Emergency Medicine Physician
Generated Narrative: Location org-Loc-ED-Metro-Hospital status: Active name: Metro Hospital Emergency Department telecom: ph: (555) 384-4444 address: 22327 Moross Rd, Detroit, MI 48236
Generated Narrative: Organization org-HomeHealth-Motown Profile: US Core Organization Profile version: 8.0.1 active: true name: Motown Home Health Grand Rapids telecom: ph: (210) 555-2882 address: 121 Spruce Dr. Grand Rapids, MI 49503
Generated Narrative: Practitioner Practitioner-JudySalas version: 4; Last updated: 2024-09-21 14:11:15+0000 identifier: http://example.org/fhir/MI-state-license/480410286 active: true name: Judy Salas telecom: ph: (555) 944-2454, jsalas@MotownHHA.com address: 17010 Harper Ave, Detroit, MI 48224 gender: Female
Generated Narrative: Practitioner Practitioner-PriyaSarkar version: 4; Last updated: 2024-09-21 14:11:15+0000 identifier: United States National Provider Identifier/4362436261 active: true name: Priya Sarkar telecom: ph: (555) 375-3777, psarkar@MetroHospital.com address: 22327 Moross Rd, Detroit, MI 48236 gender: Female
Generated Narrative: PractitionerRole PractitionerRole-Physician-PriyaSarkar active: true practitioner: Priya Sarkar organization: Metro Hospital Emergency Department code: Emergency Medicine Physician location: Location Metro Hospital Emergency Department