Generated Narrative: Patient SteffiRambeau16 Mo Female, DoB: 2009-07-18 Alt. Name: Steffi Rambeau (Official) Emergency Contact: Maria Rambeau Emergency Contact: Frank Rambeau Individual Pronouns: value: she/her/her/hers/herself Individual Pronouns: value: they/them/their/theirs/themselves <td style="background-color: #f3f5da" title="An individual's personal sense of being a man, woman, boy, girl, nonbinary, or something else. This represents an individual’s identity, ascertained by asking them what that identity is. #xA; In the case where the gender identity is communicated by a third party, for example, if a spouse indicates the gender identity of their partner on an intake form, a Provenance resource can be used with a Provenance.target referring to the Patient, with a targetElement extension identifying the gender identity extension as the target element within the Patient resource. When exchanging this concept, refer to the guidance in the [Gender Harmony Implementation Guide](http://hl7.org/xprod/ig/uv/gender-harmony/).">Individual Gender Identity: value: Non-binary gender identity
Generated Narrative: Observation SteffiRambeau16SexualOrientation Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity') status: Final code: Sexual orientation subject: Mo Female, DoB: 2009-07-18 effective: 2026-04-17 performer: Mo Female, DoB: 2009-07-18 value: Bisexual
Generated Narrative: Condition SteffiRambeau16ChronicConstipation clinicalStatus: Active category: Problem List Item code: Chronic constipation subject: Mo Female, DoB: 2009-07-18
Generated Narrative: Condition SteffiRambeau16Asthma clinicalStatus: Active category: Problem List Item code: Moderate persistent asthma subject: Mo Female, DoB: 2009-07-18
Moderate persistent asthma, uncomplicated
Generated Narrative: Condition SteffiRambeau16IrregularPeriods Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity') clinicalStatus: Active category: Problem List Item code: Irregular periods subject: Mo Female, DoB: 2009-07-18
Generated Narrative: Condition SteffiRambeau16Chlamydia Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexually transmitted disease information sensitivity (Details: ActCode code STD = 'sexually transmitted disease information sensitivity') clinicalStatus: Active category: Encounter Diagnosis code: Chlamydia infection of GU tract subject: Mo Female, DoB: 2009-07-18 recordedDate: 2026-04-17
Chlamydial infection of genitourinary tract, unspecified
Chlamydia trachomatis infection of genital structure (disorder)
Generated Narrative: Condition SteffiRambeau16MedicalAbortion Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity'), ABORTION (Details: extraSensitivityCodes code ABORTION) clinicalStatus: Resolved category: Encounter Diagnosis code: Medical Abortion age 16: Encounter for elective termination of pregnancy subject: Mo Female, DoB: 2009-07-18 recordedDate: 2025-12-18
Encounter for elective termination of pregnancy
Medical Abortion age 16: Encounter for elective termination of pregnancy
Generated Narrative: Condition SteffiRambeau16DandCAbortion Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity'), ABORTION (Details: extraSensitivityCodes code ABORTION) clinicalStatus: Resolved category: Encounter Diagnosis code: D&C age 15: Encounter for elective termination of pregnancy subject: Mo Female, DoB: 2009-07-18 recordedDate: 2024-09-18
D&C age 15: Encounter for elective termination of pregnancy
Generated Narrative: Procedure SteffiRambeau16DandCProcedure Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity'), ABORTION (Details: extraSensitivityCodes code ABORTION) status: Completed code: Dilatation and Curettage, uterus, for therapeutic Abortion subject: Mo Female, DoB: 2009-07-18 performed: 2024-09-18
Induced abortion, by dilation and curettage
Dilatation and Curettage, uterus, for therapeutic Abortion
Generated Narrative: DiagnosticReport SteffiRambeau16GCNAAT Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexually transmitted disease information sensitivity (Details: ActCode code STD = 'sexually transmitted disease information sensitivity') Gonorrhea/chlamydia urine NAAT panel (Laboratory) Subject Mo Female, DoB: 2009-07-18 When For 2026-04-17 Report Details GC result negative; CT result positive.
Generated Narrative: DiagnosticReport SteffiRambeau16HIVELISA Security Labels: restricted (Details: Confidentiality code R = 'restricted'), HIV/AIDS information sensitivity (Details: ActCode code HIV = 'HIV/AIDS information sensitivity') HIV ELISA with reflex Western blot (Laboratory) Subject Mo Female, DoB: 2009-07-18 When For 2026-04-17 Report Details HIV negative.
Generated Narrative: MedicationRequest SteffiRambeau16Miralax status: Active intent: Order medication: Miralax 17g PO daily subject: Mo Female, DoB: 2009-07-18 dosageInstruction text: 17g PO daily timing: Once per 1 day route: Oral route DoseAndRates - Dose[x] * 17 g (Details: UCUM codeg = 'g')
Generated Narrative: MedicationRequest SteffiRambeau16Albuterol status: Active intent: Order medication: Albuterol 90 mcg/puff 2 puffs INH q4h PRN wheezing subject: Mo Female, DoB: 2009-07-18 dosageInstruction text: 2 puffs INH q4h PRN wheezing timing: Once per 4 hours asNeeded: true route: Respiratory tract route DoseAndRates - Dose[x] * 90 ug (Details: UCUM codeug = 'ug')
albuterol 90 MCG/ACTUAT Metered Dose Inhaler, 200 Actuations, generic for ProAir
Albuterol 90 mcg/puff 2 puffs INH q4h PRN wheezing
Generated Narrative: MedicationRequest SteffiRambeau16Pulmicort status: Active intent: Order medication: Pulmicort Flexhaler 180mcg 2 puffs INH BID subject: Mo Female, DoB: 2009-07-18 dosageInstruction text: 2 puffs INH BID timing: 2 per 1 day route: Respiratory tract route DoseAndRates - Dose[x] * 180 ug (Details: UCUM codeug = 'ug')
Pulmicort Flexhaler 180 MCG/ACTUAT Dry Powder Inhaler, 120 ACTUAT
Pulmicort Flexhaler 180mcg 2 puffs INH BID
Generated Narrative: MedicationRequest SteffiRambeau16Loestrin Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity') status: Active intent: Order medication: Loestrin 1/20 (norethindrone acetate 1mg / ethinyl estradiol 0.02mg) 1 tab PO daily subject: Mo Female, DoB: 2009-07-18 dosageInstruction text: 1 tab PO daily timing: Once per 1 day route: Oral route DoseAndRates - Dose[x] * 1 tablet (Details: UCUM code1 = '1')
Loestrin 1/20 (norethindrone acetate 1mg / ethinyl estradiol 0.02mg) 1 tab PO daily
Generated Narrative: MedicationRequest SteffiRambeau16Azithromycin Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexually transmitted disease information sensitivity (Details: ActCode code STD = 'sexually transmitted disease information sensitivity') status: Completed intent: Order medication: Azithromycin 500mg 2 tabs x 1 subject: Mo Female, DoB: 2009-07-18 dosageInstruction text: 500mg 2 tabs x 1 dose timing: Count 1 times, Once per 1 day route: Oral route DoseAndRates - Dose[x] * 1000 mg (Details: UCUM codemg = 'mg')
Generated Narrative: MedicationRequest SteffiRambeau16Descovy Security Labels: restricted (Details: Confidentiality code R = 'restricted'), HIV/AIDS information sensitivity (Details: ActCode code HIV = 'HIV/AIDS information sensitivity') status: Active intent: Order medication: Descovy (tenofovir alafenamide 25mg and emtricitabine 200mg) one tablet PO daily subject: Mo Female, DoB: 2009-07-18 dosageInstruction text: one tablet PO daily timing: Once per 1 day route: Oral route DoseAndRates - Dose[x] * 1 tablet (Details: UCUM code1 = '1')
Descovy (tenofovir alafenamide 25mg and emtricitabine 200mg) one tablet PO daily
Generated Narrative: MedicationRequest SteffiRambeau16Mifepristone Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity'), ABORTION (Details: extraSensitivityCodes code ABORTION) status: Completed intent: Order medication: Mifepristone 200mg PO x1 subject: Mo Female, DoB: 2009-07-18 dosageInstruction text: 200mg PO x1 timing: Count 1 times, Once per 1 day route: Oral route DoseAndRates - Dose[x] * 200 mg (Details: UCUM codemg = 'mg')
Generated Narrative: MedicationRequest SteffiRambeau16Misoprostol Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity'), ABORTION (Details: extraSensitivityCodes code ABORTION) status: Completed intent: Order medication: Misoprostol 200mcg take 4 tabs BUC 24-48h after mifepristone x1 subject: Mo Female, DoB: 2009-07-18 dosageInstruction text: 200mcg take 4 tabs buccally 24-48h after mifepristone x1 timing: Count 1 times, Once per 1 day route: Buccal route DoseAndRates - Dose[x] * 800 ug (Details: UCUM codeug = 'ug')
Misoprostol 200mcg take 4 tabs BUC 24-48h after mifepristone x1
200mcg take 4 tabs buccally 24-48h after mifepristone x1
Generated Narrative: DiagnosticReport SteffiRambeau16FirstTrimesterUS Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity') First trimester ultrasound (Radiology) Subject Mo Female, DoB: 2009-07-18 When For 2024-07-18 Report Details
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation
Generated Narrative: DiagnosticReport SteffiRambeau16QuadScreen Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity'), genetic disease information sensitivity (Details: ActCode code GDIS = 'genetic disease information sensitivity') Quad screen (Laboratory) Subject Mo Female, DoB: 2009-07-18 When For 2024-08-18 Report Details
Second trimester quad maternal screen panel - Serum or Plasma
Generated Narrative: Observation SteffiRambeau16OBHx Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity') status: Final code: OB History G1P0010 subject: Mo Female, DoB: 2009-07-18 effective: 2024-07-18 performer: Practitioner Jane Smith value: G1P0010 component code: Number of births at term (observable entity) value: 0 component code: Number of preterm births (observable entity) value: 0 component code: Number of abortions (observable entity) value: 1 component code: Number of live deliveries (observable entity) value: 0
Measure of pregnancy (observable entity)
Number of births at term (observable entity)
Number of preterm births (observable entity)
Number of live deliveries (observable entity)
Generated Narrative: Observation SteffiRambeau16LMP Security Labels: restricted (Details: Confidentiality code R = 'restricted'), sexuality and reproductive health information sensitivity (Details: ActCode code SEX = 'sexuality and reproductive health information sensitivity') status: Final code: Last Menstrual Period subject: Mo Female, DoB: 2009-07-18 effective: 2026-04-17 performer: Practitioner Jane Smith value: 2026-04-03
Date of last menstrual period (observable entity)
Generated Narrative: RelatedPerson MariaRambeau16 patient: Mo Female, DoB: 2009-07-18 relationship: mother name: Maria Rambeau
Generated Narrative: RelatedPerson FrankRambeau16 patient: Mo Female, DoB: 2009-07-18 relationship: father name: Frank Rambeau
Generated Narrative: Practitioner SteffiRambeauDoctor name: Jane Smith