Generated Narrative: Composition BSJ-TOCComposition 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 Jen Cadbury title: Transitions of Care Document for Betsy Smith-Johnson custodian: Organization Happy Nursing Facility
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-Patient1 Last updated: 2021-03-29 14:25:34-0500; Language: en-US Profile: US Core Patient Profileversion: null8.0.1) Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) Active: true Marital Status: unknown Other Id: Medical Record Number/1032702 (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: Encounter BSJ-Encounter Profile: US Core Encounter Profileversion: null8.0.1) status: Finished class: ActCode: HH (Home Health) type: Evaluation and management of patient at home (procedure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) Participants - Individual * PractitionerRole Occupational Therapist period: 2024-01-18 --> (ongoing)
Evaluation and management of patient at home (procedure)
Generated Narrative: AllergyIntolerance BSJ-AllergyACE Profile: US Core AllergyIntolerance Profileversion: null8.0.1) clinicalStatus: Active verificationStatus: Confirmed category: Medication criticality: High Risk code: Substance with angiotensin-converting enzyme inhibitor mechanism of action (substance) patient: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) asserter: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) lastOccurrence: 2011-10 Reactions - Substance Manifestation * captopril 12.5 MG Oral Tablet Hyperkalemia caused by angiotensin-converting enzyme inhibitor (disorder)
Substance with angiotensin-converting enzyme inhibitor mechanism of action (substance)
Hyperkalemia caused by angiotensin-converting enzyme inhibitor (disorder)
Generated Narrative: Condition BSJ-AnemiaDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) Condition Asserted Date: 2024-04-23 13:15:00-0400 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Anemia co-occurrent and due to chronic kidney disease stage 3 (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#10A3D58WH1600) recordedDate: 2024-04-23 13:15:00-0400 note: See lab
Anemia co-occurrent and due to chronic kidney disease stage 3 (disorder)
Structure of cardiovascular system (body structure)
Generated Narrative: Condition BSJ-ConstipationDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) Condition Asserted Date: 2020-11 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Drug-induced constipation (disorder) bodySite: Colon structure (body structure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) asserter: PractitionerRole Internal Medicine Physician
Generated Narrative: Condition BSJ-DepressionDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) 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#10A3D58WH1600)
Generated Narrative: Condition BSJ-DiabetesDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) 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#10A3D58WH1600) 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 BSJ-DressingConcern Profile: US Core Condition Problems and Health Concerns Profileversion: null8.0.1) clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item code: Difficulty performing dressing activity (finding) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) recordedDate: 2024-04-27 15:40:00-0400 asserter: PractitionerRole Occupational Therapist note: Betsy is frustrated, embarrassed, and worried about not being able to dress herself
Difficulty performing dressing activity (finding)
Betsy is frustrated, embarrassed, and worried about not being able to dress herself
Generated Narrative: Condition BSJ-HeartDiseaseDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) Condition Asserted Date: 2019-06 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Ischemic heart disease (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#10A3D58WH1600) recordedDate: 2019-06-08 14:15:00-0400 asserter: PractitionerRole Internal Medicine Physician
Generated Narrative: Condition BSJ-HemiparesisDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) Condition Asserted Date: 2024-04-18 13:30:00-0400 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Right hemiparesis (disorder) bodySite: Right upper arm structure (body structure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) onset: 2024-04-17 15:40:00-0400 recordedDate: 2024-04-18 13:30:00-0400 asserter: PractitionerRole Neurology Physician note: Patient began experiencing right sided weakness, primarily in arm and shoulder. There was no facial droop, but patient reports "tingling" in R face / numbness along R brow. Symptoms in face resolved post tPA administration. Strength improved in shoulder, weakness did not fully resolve. Demonstrates R arm weakness and lack of coordination. Fine motor skills significantly degraded and have not improved post tPA.
Right upper arm structure (body structure)
Patient began experiencing right sided weakness, primarily in arm and shoulder. There was no facial droop, but patient reports "tingling" in R face / numbness along R brow. Symptoms in face resolved post tPA administration. Strength improved in shoulder, weakness did not fully resolve. Demonstrates R arm weakness and lack of coordination. Fine motor skills significantly degraded and have not improved post tPA.
Generated Narrative: Condition BSJ-HyperlipidemiaDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) 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#10A3D58WH1600) asserter: PractitionerRole Internal Medicine Physician
Generated Narrative: Condition BSJ-HypertensionDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) Condition Asserted Date: 2011-09 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Hypertensive disorder, systemic arterial (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#10A3D58WH1600) onset: 2011-08 recordedDate: 2011-09-17 asserter: PractitionerRole Internal Medicine Physician
Hypertensive disorder, systemic arterial (disorder)
Generated Narrative: Condition BSJ-KidneyDiseaseDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) Condition Asserted Date: 2021-04 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Chronic kidney disease stage 3 due to type 2 diabetes mellitus (disorder) bodySite: Both kidneys (body structure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) recordedDate: 2021-04-10 15:00:00-0400 asserter: PractitionerRole Internal Medicine Physician
Chronic kidney disease stage 3 due to type 2 diabetes mellitus (disorder)
Generated Narrative: Condition BSJ-NauseaAndVomiting Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) Condition Asserted Date: 2024-04-18 16:30:00-0400 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Nausea and Vomiting (disorder) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) onset: 2024-04-18 16:30:00-0400 recordedDate: 2024-04-18 16:30:00-0400 note: Patient pressed call button for vomiting. She reports she started feeling nauseated about ten minutes ago.
Patient pressed call button for vomiting. She reports she started feeling nauseated about ten minutes ago.
Generated Narrative: Condition BSJ-NeuropathyDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) Condition Asserted Date: 2020-07 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Chronic painful neuropathy due to diabetes mellitus (disorder) bodySite: Both lower legs (body structure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) asserter: PractitionerRole Internal Medicine Physician
Chronic painful neuropathy due to diabetes mellitus (disorder)
Generated Narrative: Condition BSJ-StrokeDiagnosis Profile: US Core Condition Encounter Diagnosis Profileversion: null8.0.1) Condition Asserted Date: 2024-04-17 15:40:00-0400 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Ischemic Stroke (disorder) bodySite: Structure of middle cerebral artery M1 segment (body structure), Left subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) onset: 2024-04-17 15:40:00-0400 recordedDate: 2023-12-15 18:40:00-0400 asserter: PractitionerRole Neurology Physician note: Partial occlusion of MCA. Stroke event witnessed. EMS response / patient arrived within 45 minutes of symptom onset. Verified by CT with contrast. tPA administered within 2 hours of symptom onset.
Structure of middle cerebral artery M1 segment (body structure)
Partial occlusion of MCA. Stroke event witnessed. EMS response / patient arrived within 45 minutes of symptom onset. Verified by CT with contrast. tPA administered within 2 hours of symptom onset.
Generated Narrative: Condition BSJ-UndressingConcern Profile: US Core Condition Problems and Health Concerns Profileversion: null8.0.1) clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item code: Difficulty undressing (finding) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) recordedDate: 2024-04-27 15:40:00-0400 asserter: PractitionerRole Occupational Therapist note: Betsy is frustrated, embarrassed, and worried about not being able to undress herself
Betsy is frustrated, embarrassed, and worried about not being able to undress herself
Generated Narrative: Condition OT-ProblemList-Decondition Profile: US Core Condition Problems and Health Concerns Profileversion: null8.0.1) Condition Asserted Date: 2024-04-30 15:40:00-0400 clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item code: Physical deconditioning (finding) bodySite: Entire lower body (body structure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) onset: 2024-04-26 15:40:00-0400 recordedDate: 2024-04-30 15:40:00-0400 asserter: PractitionerRole Occupational Therapist Evidences - Detail * Observation Sit to stand - functional goal during assessment period [CMS Assessment] note: The weakness in the patient's lower extremities is secondary to deconditioning. According to the report from Neurology, patient did not have motor or sensory deficits below upper chest. High rehab potential.
The weakness in the patient's lower extremities is secondary to deconditioning. According to the report from Neurology, patient did not have motor or sensory deficits below upper chest. High rehab potential.
Generated Narrative: Condition OT-ProblemList-RightWeak Profile: US Core Condition Problems and Health Concerns Profileversion: null8.0.1) Condition Asserted Date: 2024-04-17 15:40:00-0400 clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item code: Muscle weakness of upper limb (finding) bodySite: Right upper arm structure (body structure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) recordedDate: 2024-04-27 15:40:00-0400 asserter: PractitionerRole Occupational Therapist Evidences - Detail * Condition Right hemiparesis (disorder) note: The weakness and lack of coordination in the patient's right shoulder, arm, and hand are secondary to the stroke. PT/OT from SNF report improvements to rotator cuff strength over last month.
The weakness and lack of coordination in the patient's right shoulder, arm, and hand are secondary to the stroke. PT/OT from SNF report improvements to rotator cuff strength over last month.
Generated Narrative: Observation BSJ-MDS-Doffing1 Profile: Personal Functioning and Engagement Single Observation Event Location: Location Happy Nursing Facility status: Final category: Survey, Functional Status, Taking off clothes code: Upper body dressing - functional goal during assessment period [CMS Assessment] subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) effective: 2024-05-16 14:30:00-0400 performer: PractitionerRole Occupational Therapist value: Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.
Upper body dressing - functional goal during assessment period [CMS Assessment]
Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.
Generated Narrative: Observation BSJ-MDS-Donning1 Profile: Personal Functioning and Engagement Single Observation Event Location: Location Happy Nursing Facility status: Final category: Survey, Functional Status, Putting on clothes code: Lower body dressing - functional goal during assessment period [CMS Assessment] subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) effective: 2024-05-16 14:30:00-0400 performer: PractitionerRole Occupational Therapist value: Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.
Lower body dressing - functional goal during assessment period [CMS Assessment]
Generated Narrative: Observation BSJ-MDS-Mobility-PT1 Profile: Personal Functioning and Engagement Collection Event Location: Location Happy Nursing Facility status: Final category: Survey, Functional Status, MOBILITY code: MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment] subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) effective: 2024-05-16 14:30:00-0400 performer: PractitionerRole Occupational Therapist hasMember: Observation Sit to stand - functional goal during assessment period [CMS Assessment]
MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
Generated Narrative: Observation BSJ-MDS-SitStand1 Profile: Personal Functioning and Engagement Single Observation Event Location: Location Happy Nursing Facility status: Final category: Survey, Functional Status, Standing code: Sit to stand - functional goal during assessment period [CMS Assessment] subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) effective: 2024-05-16 14:30:00-0400 performer: PractitionerRole Occupational Therapist value: Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
Sit to stand - functional goal during assessment period [CMS Assessment]
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
Generated Narrative: List BSJ-SMPMedList Home Medication List Date: 2024-08-11 Mode: Working List Status: Current Code: Patient generated medication list [Identifier] Episode Pharmacy Subject: Betsy Smith-Johnson Items Date atorvastatin 40 MG Oral Tablet 2024-08-11 sertraline 25 MG Oral Tablet 2024-08-11 furosemide 20 MG Oral Tablet 2024-08-11 carvedilol 6.25 MG Oral Tablet 2024-08-11 24 HR glipizide 2.5 MG Extended Release Oral Tablet 2024-08-11 rosuvastatin calcium 5 MG Oral Tablet 2024-08-11 acetaminophen 650 MG Oral Tablet 2024-08-11 ferrous sulfate 325 MG (iron 65 MG) Oral Tablet 2024-08-11
Patient generated medication list [Identifier] Episode Pharmacy
24 HR glipizide 2.5 MG Extended Release Oral Tablet
ferrous sulfate 325 MG (iron 65 MG) Oral Tablet
Generated Narrative: MedicationStatement BSJ-SMPMedStmt1 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: Happy Nursing Facility reasonCode: Hyperlipidemia Dosages - Sequence Text * 1 po nightly
Generated Narrative: MedicationStatement BSJ-SMPMedStmt2 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: Happy Nursing Facility reasonCode: Depressive disorder (disorder) Dosages - Sequence Text * 1 po nightly
Generated Narrative: MedicationStatement BSJ-SMPMedStmt3 basedOn: MedicationRequest: status = active; intent = order; medication[x] = furosemide 20 MG Oral Tablet; authoredOn = 2024-08-11; reasonCode = Chronic kidney disease stage 3 due to type 2 diabetes mellitus (disorder) status: Active medication: furosemide 20 MG Oral Tablet subject: Betsy Smith-Johnson dateAsserted: 2024-08-11 informationSource: Happy Nursing Facility reasonCode: Chronic kidney disease stage 3 due to type 2 diabetes mellitus (disorder) Dosages - Sequence Text * 1 po daily
Generated Narrative: MedicationStatement BSJ-SMPMedStmt4 basedOn: MedicationRequest: status = active; intent = order; medication[x] = carvedilol 6.25 MG Oral Tablet; authoredOn = 2024-08-11; reasonCode = Hypertensive disorder, systemic arterial (disorder) status: Active medication: carvedilol 6.25 MG Oral Tablet subject: Betsy Smith-Johnson dateAsserted: 2024-08-11 informationSource: Happy Nursing Facility reasonCode: Hypertensive disorder, systemic arterial (disorder) Dosages - Sequence Text * 1 po twice daily
Generated Narrative: MedicationStatement BSJ-SMPMedStmt5 basedOn: MedicationRequest: status = active; intent = order; medication[x] = 24 HR glipizide 2.5 MG Extended Release Oral Tablet; authoredOn = 2024-08-11; reasonCode = Diabetes mellitus type 2 in nonobese (disorder) status: Active medication: 24 HR glipizide 2.5 MG Extended Release Oral Tablet subject: Betsy Smith-Johnson dateAsserted: 2024-08-11 informationSource: Happy Nursing Facility reasonCode: Diabetes mellitus type 2 in nonobese (disorder) Dosages - Sequence Text * 1 daily
Generated Narrative: MedicationStatement BSJ-SMPMedStmt6 basedOn: MedicationRequest: status = active; intent = order; medication[x] = rosuvastatin calcium 5 MG Oral Tablet; authoredOn = 2024-08-11; reasonCode = Osteopenia status: Active medication: rosuvastatin calcium 5 MG Oral Tablet subject: Betsy Smith-Johnson dateAsserted: 2024-08-11 informationSource: Happy Nursing Facility reasonCode: Osteopenia Dosages - Sequence Text * 1 Calcium 500 mg
Generated Narrative: MedicationStatement BSJ-SMPMedStmt7 basedOn: MedicationRequest: status = active; intent = order; medication[x] = acetaminophen 650 MG Oral Tablet; authoredOn = 2024-08-11; reasonCode = Osteoarthritis (disorder) status: Active medication: acetaminophen 650 MG Oral Tablet subject: Betsy Smith-Johnson dateAsserted: 2024-08-11 informationSource: Happy Nursing Facility reasonCode: Osteoarthritis (disorder) Dosages - Sequence Text * 1 every 6 hours or as needed for pain
Generated Narrative: MedicationStatement BSJ-SMPMedStmt8 basedOn: MedicationRequest: status = active; intent = order; medication[x] = ferrous sulfate 325 MG (iron 65 MG) Oral Tablet; authoredOn = 2024-08-11; reasonCode = Anemia co-occurrent and due to chronic kidney disease stage 3 (disorder) status: Active medication: ferrous sulfate 325 MG (iron 65 MG) Oral Tablet subject: Betsy Smith-Johnson dateAsserted: 2024-08-11 informationSource: Happy Nursing Facility reasonCode: Anemia co-occurrent and due to chronic kidney disease stage 3 (disorder) Dosages - Sequence Text * 1 three times a day before meals
Generated Narrative: MedicationRequest BSJ-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: Dr. Jen Cadbury reasonCode: Hyperlipidemia DosageInstructions - Sequence Text * 1 po nightly
Generated Narrative: MedicationRequest BSJ-SMPMedReq2 Profile: US Core MedicationRequest Profile status: Active intent: Order medication: sertraline 25 MG Oral Tablet subject: Betsy Smith-Johnson authoredOn: 2024-08-11 requester: Dr. Jen Cadbury reasonCode: Depressive disorder (disorder) DosageInstructions - Sequence Text * 1 po nightly
Generated Narrative: MedicationRequest BSJ-SMPMedReq3 Profile: US Core MedicationRequest Profile status: Active intent: Order medication: furosemide 20 MG Oral Tablet subject: Betsy Smith-Johnson authoredOn: 2024-08-11 requester: Dr. Jen Cadbury reasonCode: Chronic kidney disease stage 3 due to type 2 diabetes mellitus (disorder) DosageInstructions - Sequence Text * 1 po daily
Generated Narrative: MedicationRequest BSJ-SMPMedReq4 Profile: US Core MedicationRequest Profile status: Active intent: Order medication: carvedilol 6.25 MG Oral Tablet subject: Betsy Smith-Johnson authoredOn: 2024-08-11 requester: Dr. Jen Cadbury reasonCode: Hypertensive disorder, systemic arterial (disorder) DosageInstructions - Sequence Text * 1 po twice daily
Generated Narrative: MedicationRequest BSJ-SMPMedReq5 Profile: US Core MedicationRequest Profile status: Active intent: Order medication: 24 HR glipizide 2.5 MG Extended Release Oral Tablet subject: Betsy Smith-Johnson authoredOn: 2024-08-11 requester: Dr. Jen Cadbury reasonCode: Diabetes mellitus type 2 in nonobese (disorder) DosageInstructions - Sequence Text * 1 daily
Generated Narrative: MedicationRequest BSJ-SMPMedReq6 Profile: US Core MedicationRequest Profile status: Active intent: Order medication: rosuvastatin calcium 5 MG Oral Tablet subject: Betsy Smith-Johnson authoredOn: 2024-08-11 requester: Dr. Jen Cadbury reasonCode: Osteopenia DosageInstructions - Sequence Text * 1 Calcium 500 mg
Generated Narrative: MedicationRequest BSJ-SMPMedReq7 Profile: US Core MedicationRequest Profile status: Active intent: Order medication: acetaminophen 650 MG Oral Tablet subject: Betsy Smith-Johnson authoredOn: 2024-08-11 requester: Dr. Jen Cadbury reasonCode: Osteoarthritis (disorder) DosageInstructions - Sequence Text * 1 every 6 hours or as needed for pain
Generated Narrative: MedicationRequest BSJ-SMPMedReq8 Profile: US Core MedicationRequest Profile status: Active intent: Order medication: ferrous sulfate 325 MG (iron 65 MG) Oral Tablet subject: Betsy Smith-Johnson authoredOn: 2024-08-11 requester: Dr. Jen Cadbury reasonCode: Anemia co-occurrent and due to chronic kidney disease stage 3 (disorder) DosageInstructions - Sequence Text * 1 three times a day before meals
Generated Narrative: CarePlan BSJ-SNFDischargeCarePlan Profile: US Core CarePlan Profileversion: null8.0.1) 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#10A3D58WH1600) activity reference: ServiceRequest Follow-up visit (procedure) activity reference: ServiceRequest Informing doctor (procedure) activity reference: ServiceRequest Occupational therapy assessment (procedure) activity reference: ServiceRequest Speech therapy assessment (procedure) activity reference: ServiceRequest Decreased protein and/or protein derivative diet (regime/therapy) activity reference: ServiceRequest Decreased sodium diet (regime/therapy) activity reference: ServiceRequest Blood chemistry (procedure) activity reference: ServiceRequest Complete blood count without differential (procedure) activity reference: ServiceRequest Physical therapy assessment (procedure)
Generated Narrative: ServiceRequest BSJ-PCPFollowUp Profile: US Core ServiceRequest Profileversion: null8.0.1) 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#10A3D58WH1600) occurrence: 2024-05-28 authoredOn: 2024-05-18 requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Generated Narrative: ServiceRequest BSJ-SNFDischargeCallOrder Profile: US Core ServiceRequest Profileversion: null8.0.1) status: Active intent: Order category: Evaluation procedure (procedure) priority: Routine code: Informing doctor (procedure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) occurrence: 2024-05-18 --> (ongoing) authoredOn: 2024-05-18 requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Generated Narrative: ServiceRequest BSJ-SNFDischargeCallOTRefer Profile: US Core ServiceRequest Profileversion: null8.0.1) status: Active intent: Order category: Evaluation procedure (procedure) priority: Routine code: Occupational therapy assessment (procedure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) occurrence: 2024-05-18 --> (ongoing) authoredOn: 2024-05-18 requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician reasonReference: Condition Right hemiparesis (disorder)
Occupational therapy assessment (procedure)
Generated Narrative: ServiceRequest BSJ-SNFDischargeCallSLPRefer Profile: US Core ServiceRequest Profileversion: null8.0.1) status: Active intent: Order category: Evaluation procedure (procedure) priority: Routine code: Speech therapy assessment (procedure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) occurrence: 2024-05-18 --> (ongoing) authoredOn: 2024-05-18 requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Generated Narrative: ServiceRequest BSJ-SNFDischargeDietProtein Profile: US Core ServiceRequest Profileversion: null8.0.1) status: Active intent: Order category: Evaluation procedure (procedure) priority: Routine code: Decreased protein and/or protein derivative diet (regime/therapy) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) occurrence: 2024-05-18 --> (ongoing) authoredOn: 2024-05-18 requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician reasonReference: Condition Chronic kidney disease stage 3 due to type 2 diabetes mellitus (disorder)
Decreased protein and/or protein derivative diet (regime/therapy)
Generated Narrative: ServiceRequest BSJ-SNFDischargeDietSalt Profile: US Core ServiceRequest Profileversion: null8.0.1) status: Active intent: Order category: Evaluation procedure (procedure) priority: Routine code: Decreased sodium diet (regime/therapy) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) occurrence: 2024-05-18 --> (ongoing) authoredOn: 2024-05-18 requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician reasonReference: Condition Ischemic heart disease (disorder) Condition Chronic kidney disease stage 3 due to type 2 diabetes mellitus (disorder)
Generated Narrative: ServiceRequest BSJ-SNFDischargeLabOrderBMP Profile: US Core ServiceRequest Profileversion: null8.0.1) status: Active intent: Order category: Laboratory procedure priority: Routine code: Blood chemistry (procedure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) occurrence: 2024-05-28 authoredOn: 2024-05-18 requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician reasonReference: Condition Anemia co-occurrent and due to chronic kidney disease stage 3 (disorder) Condition Hyperlipidemia (disorder) Condition Chronic kidney disease stage 3 due to type 2 diabetes mellitus (disorder) Condition Diabetes mellitus type 2 in nonobese (disorder)
Generated Narrative: ServiceRequest BSJ-SNFDischargeLabOrderCBC Profile: US Core ServiceRequest Profileversion: null8.0.1) status: Active intent: Order category: Laboratory procedure priority: Routine code: Complete blood count without differential (procedure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) occurrence: 2024-05-28 authoredOn: 2024-05-18 requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician reasonReference: Condition Anemia co-occurrent and due to chronic kidney disease stage 3 (disorder)
Complete blood count without differential (procedure)
Generated Narrative: ServiceRequest BSJ-SNFDischargePTRefer Profile: US Core ServiceRequest Profileversion: null8.0.1) status: Active intent: Order category: Evaluation procedure (procedure) priority: Routine code: Physical therapy assessment (procedure) subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600) occurrence: 2024-05-18 --> (ongoing) authoredOn: 2024-05-18 requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician reasonReference: Condition Right hemiparesis (disorder)
Generated Narrative: Location org-Loc-Neuro-Care-Inc Profile: US Core Location Profileversion: null8.0.1) status: Active name: Neuro Care Inc. address: 177 Branching Tree Blvd, Grand Rapids, MI 49509
177 Branching Tree Blvd, Grand Rapids, MI 49509
Generated Narrative: Location org-Loc-PC-Primary-Care-Michigan Profile: US Core Location Profileversion: null8.0.1) status: Active name: Michigan Primary Health Care Associates address: 123 Spruce Dr. Grand Rapids, MI 49503
Generated Narrative: Location org-Loc-SNF-Happy-Nursing-Facility Profile: US Core Location Profileversion: null8.0.1) status: Active name: Happy Nursing Facility address: 8100 Pinebrook Dr, Grand Rapids, MI 49504
8100 Pinebrook Dr, Grand Rapids, MI 49504
Generated Narrative: Organization org-Neuro-Care-Inc Profile: US Core Organization Profileversion: null8.0.1) active: true name: Neuro Care Inc. telecom: ph: (210) 555 5555 address: 177 Branching Tree Blvd, Grand Rapids, MI 49509
Generated Narrative: Organization org-PC-Primary-Care-Michigan Profile: US Core Organization Profileversion: null8.0.1) active: true name: Michigan Primary Health Care Associates telecom: ph: (616) 555-1212 address: 123 Spruce Dr. Grand Rapids, MI 49503
Generated Narrative: Organization org-SNF-Happy-Nursing-Facility Profile: US Core Organization Profileversion: null8.0.1) active: true name: Happy Nursing Facility telecom: ph: (210) 555 1871 address: 8100 Pinebrook Dr, Grand Rapids, MI 49504
Generated Narrative: Practitioner Example-AnitaChu Profile: US Core Practitioner Profileversion: null8.0.1) identifier: United States National Provider Identifier/8134258523 active: true name: Anita Chu telecom: ph: (616) 555-1212 address: 123 Spruce Dr. Grand Rapids, MI 49503 gender: Female
Generated Narrative: Practitioner Example-GeraldPark Profile: US Core Practitioner Profileversion: null8.0.1) identifier: United States National Provider Identifier/8554084011 active: true name: Gerald Park telecom: ph: (555) 566 3494 address: 8100 Pinebrook Dr, Grand Rapids, MI 49504 gender: Male
Generated Narrative: Practitioner Example-JenCadbury Profile: US Core Practitioner Profileversion: null8.0.1) identifier: United States National Provider Identifier/9635749481 active: true name: Jen Cadbury telecom: ph: (210) 555 1871 address: 8100 Pinebrook Dr, Grand Rapids, MI 49504 gender: Female
Generated Narrative: Practitioner Example-NuraMekel Profile: US Core Practitioner Profileversion: null8.0.1) identifier: United States National Provider Identifier/8224780964 active: true name: Nura Mekel telecom: ph: (210) 555 5555 address: 177 Branching Tree Blvd, Grand Rapids, MI 49509 gender: Female
Generated Narrative: PractitionerRole Role-IMMD-AnitaChu Profile: US Core PractitionerRole Profileversion: null8.0.1) active: true practitioner: Dr. Anita Chu organization: Michigan Primary Health Care Associates code: Internal Medicine Physician location: Location Michigan Primary Health Care Associates telecom: ph: (616) 555-1212
Generated Narrative: PractitionerRole Role-Neuro-NuraMekel Profile: US Core PractitionerRole Profileversion: null8.0.1) active: true practitioner: Nura Mekel organization: Neuro Care Inc. code: Neurology Physician location: Location Neuro Care Inc. telecom: ph: (210) 555 5555
Generated Narrative: PractitionerRole Role-OT-JenCadbury Profile: US Core PractitionerRole Profileversion: null8.0.1) active: true practitioner: Jen Cadbury organization: Happy Nursing Facility code: Occupational Therapist location: Location Happy Nursing Facility telecom: ph: (210) 555 1871
Generated Narrative: PractitionerRole Role-SNFDoc-GeraldPark Profile: US Core PractitionerRole Profileversion: null8.0.1) active: true practitioner: Gerald Park organization: Happy Nursing Facility code: Geriatric Medicine (Family Medicine) Physician location: Location Happy Nursing Facility telecom: ph: (555) 566 3494
Geriatric Medicine (Family Medicine) Physician