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
CodeineShortness of BreathUnknownActive
aspirinHivesUnknownActive
PENICILLIN G BENZATHINEHivesUnknownActive
 Codeine aspirin PENICILLIN G BENZATHINE
Medications
Medication Instructions Dosage Effective Dates (start - stop) Status Comments
metoprolol tartrate 25 mg tablettake 1 tablet by oral route every day25 MGFeb-12-2013 - Active
clarithromycin 500 mg tablettake 1 tablet by oral route 2 times daily for 7 days Aug-06-2012 - Active
albuterol sulfate HFA 90 mcg/actuation Aerosol Inhalerinhale 2 puff by inhalation route every 4 - 6 hours as needed as needed for Wheezing0Apr-02-2012 - Apr-02-2013Active
albuterol sulfate HFA 90 mcg/actuation Aerosol Inhalerinhale 2 puffs once as needed Aug-06-2012 - Aug-06-2012No Longer ActiveAdministered 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 pneumoniaJan-25-2013 - Active
AsthmaJan-25-2013 - Controlled
HypoxemiaJan-25-2013 - Mild
Procedures
Procedure Date
Immunization admin, 1 vaccineJan-25-2013
Immunization admin, 1 vaccineJan-25-2013
Immunization admin, 1 vaccineJan-25-2013
Immunization admin, 1 vaccineJan-25-2013
CHEST COMPRESSION GEN SYSTEMAug-06-2012
Results
Test Name Date and Time Measure Units Reference Range Abnormal Flag Comments
Unknown
Advance Directives
Directive Yes / No Effective Date
ResuscitationYes8/6/2012
Life SupportYes8/6/2012
IntubationYes8/6/2012
AntibioticsYes8/6/2012
IV Fluid SupportYes8/6/2012
Tube FeedYes8/6/2012
CPRYes8/6/2012
Other DirectiveYes8/6/2012
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 VisitNEXTGEN Medical Practice (Horsham), 795 Horsham Road, Horsham, PA, 19044 tel:+1-2156577010Get 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-06-2012completed- Completed reason: New
Influenza Virus vaccineSep-10-2011completed- Completed reason: New
Influenza Virus vaccineNov-01-2010completed- Completed reason: New
Td (7 yrs or older)Jan-04-2007completed- 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 StatusCurrent every day smoker1992
Vital Signs
Date / Time: Height Weight BMI Pulse Rate Blood Pressure Temperature Respiratory Rate Body Surface Area Head Circumference
Aug-06-2012/12:13:0069.69 in194.01 lbs28.08 135/92 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-12-2013GoalColonoscopy. Due on Sep-22-2012due
Feb-15-2013Referralreferred 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 09:00AppointmentJones, Isabella --- Dr. Henry Seven, 1007 Healthcare Dr., Portland, OR 99123 On Test Date + 3 WeeksBOOKED
02/19/2013 08:10AppointmentJones, IsabellaBOOKED
Aug-06-2012Patient EducationStopping Smoking: After Your Visitcompleted
Feb-18-2013Future Order: Lab OrderSputum Culture (Sputum Clt), Collected on: Aug-06-2012Ordered
Feb-18-2013Future Order: Radiology OrderChest X-ray (CXR), Scheduled on: Aug-13-2012Ordered
Feb-18-2013Future Order: Radiology OrderChest x-ray, two views (71020), Body Site: Lower Respiratory Tract Strcture, Collected on: Aug-06-2012Ordered
Feb-18-2013Future Order: Lab OrderHGB (NG005041), Scheduled on: Aug-13-2012Ordered
History Of Present Illness Mild Fever, 2 days Chills, 2 days Cough productive of greenish sputum, 2 days
Functional Status
Functional / Cognitive Date Status
CognitiveAug-06-2012No impairment
FunctionalAug-06-2012Active
Medications Administered
Medication Instructions Dosage Effective Dates (start - stop) Status Comments
albuterol sulfate HFA 90 mcg/actuation Aerosol Inhalerinhale 2 puffs once as needed Aug-06-2012 - Aug-06-2012No Longer ActiveAdministered 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-12-2013Patient may continue to experience low grade fever and chills.Related to Community acquired pneumonia
Feb-12-2013Return to clinic or call 911 if you experience chest pain, shortness of breath, high fevers, or intractable vomiting/diarrheaRelated to Community acquired pneumonia