Department of Veterans Affairs Summarization of Episode Note 123 Anywhere Road Anywhere DC 00001 NWHINONE NWHINZZZTESTPATIENT MALE MARRIED Department of Veterans Affairs Department of Veterans Affairs Department of Veterans Affairs BRUUN,JESSE MARTINSBURG VAMC CHDRAMDPROV,ALICIA M MARTINSBURG VAMC POST,WALTER MARTINSBURG VAMC Providerone, Providerone CHEYENNE HDR SQA Providerone, Providerone CHEYENNE HDR SQA providerone,providerone CHEYENNE HDR SQA POND,NEAL CHEYENNE HDR SQA POND,NEAL CHEYENNE HDR SQA providerone,providerone CHEYENNE HDR SQA providerone,providerone CHEYENNE HDR SQA
Allergies
Department of Veterans Affairs Business Rules for Construction of Medical Information
Allergies This section contains all patient allergy information from all VA treatment facilities. It does not contain patient allergies that were deleted or entered in error.
Allergy Verification Date Event Type Reaction Severity Source
TRIMETHOPRIM 16 OCT 2012 @1634 Propensity to adverse reactions to drug None -- MARTINSBURG VAMC
LATEX STRAP 26 JUN 2012 @1410 Propensity to adverse reactions to drug URTICARIA -- MARTINSBURG VAMC
BEE VENOM 15 OCT 2012 @1057 Propensity to adverse reactions ANXIETY -- MARTINSBURG VAMC
BEEF PRODUCTS 16 OCT 2012 @1634 Propensity to adverse reactions to food ANXIETY -- MARTINSBURG VAMC
SOY MILK 13 NOV 2012 @1326 Propensity to adverse reactions to substance NAUSEA AND VOMITING MODERATE MARTINSBURG VAMC
BAKED BEANS 13 NOV 2012 @1622 Propensity to adverse reactions to food DIARRHEA MODERATE MARTINSBURG VAMC
DRUG LATEX STRAP OTHER BEE VENOM FOOD BEEF PRODUCTS DRUG, FOOD SOY MILK FOOD BAKED BEANS FOOD WATERMELONS FOOD HONEY DRUG, FOOD NUTS DRUG, FOOD OATS DRUG, FOOD CHOCOLATE
Problems/Conditions
Department of Veterans Affairs Business Rules for Construction of Medical Information
Problems/Conditions This section contains patient conditions (active and inactive) information from all VA treatment facilities. It does not contain patient conditions that were deleted.
Problem Status Problem Code Date of Onset Provider Source
Diabetic Foot Ulcer Active 250.80 15 MAY 2012 Providerone,Providerone MARTINSBURG VAMC
Diabetes Active 250.01 14 FEB 2012 Providerone,Providerone MARTINSBURG VAMC
Cough Active 786.2 14 MAR 2012 Providertwo,Providertwo MARTINSBURG VAMC
Allergic arthritis of multiple sites Active 716.29 10 MAR 2012 Providerthree, Providerthree MARTINSBURG VAMC
Weakness of limb Active 728.87 -- Providerfour,Providerfour MARTINSBURG VAMC
Arthritis, Rheumatoid Active 714.0 20 OCT 2011 Providerone,Providerone CHEYENNE HDR SQA
Obesity in Diabetes Active 278.00 24 OCT 2011 Providerone,Providerone CHEYENNE HDR SQA
Aneurysm, Aorta, Abdominal Active 441.4 -- Providerfive,Providerfive CHEYENNE HDR SQA
Cough Active 786.2 -- Providerfive,Providerfive CHEYENNE HDR SQA
Dermatomyositis Active 710.3 -- Providerfive,Providerfive CHEYENNE HDR SQA
Hypertension Active 401.9 -- Providerone,Providerone CHEYENNE HDR SQA
Problem Type Not Available ACTIVE Problem Type Not Available ACTIVE Problem Type Not Available ACTIVE Problem Type Not Available ACTIVE Problem Type Not Available ACTIVE Problem Type Not Available ACTIVE Problem Type Not Available ACTIVE Problem Type Not Available ACTIVE Problem Type Not Available ACTIVE Problem Type Not Available ACTIVE
Medications - Prescription and Non-Prescription
Department of Veterans Affairs Business Rules for Construction of Medical Information
Medications This section contains patient medications (outpatient and self-reported) information from all VA treatment facilities for which the dispense date was within the last 15 months. Only medications that have an active or non-active prescription status are listed.
Medication Status Quantity Order Expiration Provider Prescription Dispense Date Sig Source
ASPIRIN 81MG TAB,EC Active 60 16 JAN 2013 Providerone, Providerone 000000001 17 DEC 2012 TAKE TWO TABLETS BY MOUTH DAILY FOR CIRCULATION MARTINSBURG VAMC
Prescription ACTIVE
Vital Signs
Department of Veterans Affairs Business Rules for Construction of Medical Information
Vital Signs This section contains information from the ten most recent patient vital signs (inpatient and outpatient) from all VA treatment facilities for which the panel date taken was within the last 12 months. Note: If more than one panel was taken on the same date, only the most recent panel is populated for that date.
Date Measurements Source
26 APR 2012 @1750 Heart rate: 78/min Resp rate: 80/min Body temperature: 99.6[degF] MARTINSBURG VAMC
22 APR 2012 @1740 Bdy height: 75[in_us] Heart rate: 50/min SaO2% BldC Oximetry: 34% Resp rate: 35/min Body temperature: 105[degF] Weight Measured: 165[lb_av] BP sys: 130mm[Hg] BP dias: 75mm[Hg] CHEYENNE VAMC
21 MAR 2012 @1410 Heart rate: 78/min BP sys: 120mm[Hg] BP dias: 80mm[Hg] MARTINSBURG VAMC
12 JAN 2012 @1229 Bdy height: 67[in_us] Heart rate: 110/min SaO2% BldC Oximetry: 77% Resp rate: 62/min Body temperature: 98.6[degF] Weight Measured: 162[lb_av] BP sys: 130mm[Hg] BP dias: 76mm[Hg] CHEYENNE VAMC
Vital Sign Observation Text Not Available PULSE TEMPERATURE HEIGHT PULSE PULSE OXIMETRY RESPIRATION TEMPERATURE WEIGHT SYSTOLIC BLOOD PRESSURE DIASTOLIC BLOOD PRESSURE
Lab Results - Chemistry and Hematology
Department of Veterans Affairs Business Rules for Construction of Medical Information
Lab Results This section contains the five most recent patient Chemistry and Hematology lab results from all VA treatment facilities for which the result date was within the last 12 months. A 7 day hold was implemented from date of Verification to provide an opportunity to the provider to discuss these results with the patient.
Date/Time Result Type Source Result - Unit Interpretation Reference Range Status Comment
06 DEC 2012 @0900 Glucose [Mass/volume] in Serum or Plasma MARTINSBURG VAMC 115 mg/dl High 65-110 completed --
06 NOV 2012 @1450 HDL MARTINSBURG VAMC 60 mg/dl High 35-55 completed --
04 NOV 2012 @1330 CHEM BASIC PANEL MARTINSBURG VAMC -- -- -- completed --
-- Urea nitrogen [Mass/volume] in Serum or Plasma -- 10 MG/DL -- 6-20 completed For eGFR: Race unknown, if African American multiply result by 1.210
-- Glucose [Mass/volume] in Serum or Plasma -- 90 mg/dl -- 65-110 completed ~For Test: GLUCOSE ~Glucose for testing Ordering Provider: Providerone Report Released Date/Time: Dec 06, 2012@18:33 Performing Lab: MARTINSBURG VAMC 111 STREET NAME DESIGNATION MARTINSBURG, WV POSTAL CODE
-- Creatinine [Mass/volume] in Serum or Plasma -- 1.1 mg/dl -- .5-1.4 completed For eGFR: Race unknown, if African American multiply result by 1.210
-- Sodium [Moles/volume] in Serum or Plasma -- 140 mEq/L -- 136-145 completed For eGFR: Race unknown, if African American multiply result by 1.210
-- Potassium [Moles/volume] in Serum or Plasma -- 5.0 mEq/L -- 3.6-5.1 completed For eGFR: Race unknown, if African American multiply result by 1.210
-- Chloride [Moles/volume] in Serum or Plasma -- 100 mEq/L -- 98-108 completed For eGFR: Race unknown, if African American multiply result by 1.210
-- Carbon dioxide, total [Moles/volume] in Serum or Plasma -- 30 mEq/L -- 23-33 completed For eGFR: Race unknown, if African American multiply result by 1.210
-- Calcium [Mass/volume] in Serum or Plasma -- 11.0 mg/dl High 8.5-10.5 completed For eGFR: Race unknown, if African American multiply result by 1.210
-- Anion gap 3 in Serum or Plasma -- 18.0 mEq/L High 5-17 completed For eGFR: Race unknown, if African American multiply result by 1.210
-- EGFR -- >60 -- -- completed For eGFR: Race unknown, if African American multiply result by 1.210
16 OCT 2012 @1700 HBA1C MARTINSBURG VAMC 10 % High 4.8-6.0 completed --
06 OCT 2012 @1120 MB PANEL MARTINSBURG VAMC -- -- -- completed --
-- CPK -- pending U/L -- 24-349 completed --
-- 'MB' -- pending ng/ml -- 0-5.8 completed --
-- Deprecated Creatine kinase.MB/Creatine kinase.total -- 23 High 0-5.4 completed --
Result Observation Text Not Available Result Procedure Text Not Available GLUCOSE GLUCOSE 155 MG/DL H 74-118
Immunizations
Department of Veterans Affairs Business Rules for Construction of Medical Information
Immunizations This section contains patient immunizations information from all VA treatment facilities. Only administred (i.e., not refused) immunizations are included.
Immunization Series Date Issued Reaction Comments
ADENOVIRUS,TYPE 4 -- 10 DEC 2012 -- ete NO CONTRAINDICATION; OK TO USE IN FUTURE.
MEASLES -- 25 MAY 2012 -- serious condition NO CONTRAINDICATION; OK TO USE IN FUTURE.
ADENOVIRUS,TYPE 7 -- 02 NOV 2011 -- first immunization NO CONTRAINDICATION; OK TO USE IN FUTURE.
CHOLERA, ORAL -- 02 NOV 2011 -- second immunization NO CONTRAINDICATION; OK TO USE IN FUTURE.
CHICKENPOX 1 01 NOV 2011 FEVER NO CONTRAINDICATION; OK TO USE IN FUTURE.
CHOLERA -- 01 NOV 2011 IRRITABILITY Irritability NO CONTRAINDICATION; OK TO USE IN FUTURE.
providerone, Providerone CPRSDOCTOR,BETH P ProviderOne,ProviderOne TESTER,JOHN G TESTER,JOHN G TESTER,JOHN G
History of Encounters
Department of Veterans Affairs Business Rules for Construction of Encounter Information
Encounters This section contains information for the 25 most recent historical outpatient encounters (completed) for the patient from all VA treatment facilities for which the encounter date was within the last 36 months. Note: Ancillary visits are not included. Lists of associated note titles for each encounter are limited to a maximum of 10.
Date Time Encounter Type Encounter Description Reason Arrival Departure Provider Source
10 DEC 2012 @1716 OFFICE/OUTPATIENT VISIT EST PRIMARY CARE/MEDICINE COUGH ICD9 786.2 with Provider Comments Cough (ICD-9-CM 786.2) -- -- Providerone,Providerone MARTINSBURG VAMC
1 DEC 2012 @1558 -- PRIMARY CARE/MEDICINE UNSPECIFIED DISORDER OF EYE MOVEMENTS ICD9 378.9 with Provider Comments A pattern strabismus (SNOMED CT 413380004) -- -- Providertwo,Providertwo MARTINSBURG VAMC
11 JAN 2012 @1559 -- GENERAL INTERNAL MEDICINE -- -- -- -- CHEYENNE VAMC
10 JAN 2012 @1345 -- ADMIN PAT ACTIVTIES (MASNONCT) -- -- -- -- CHEYENNE VAMC
02 NOV 2011 @1426 -- PRIMARY CARE/MEDICINE with associated notes REFERRAL NOTE RHEUMATOID ARTHRITIS ICD9 714.0 with Provider Comments Arthritis, Rheumatoid -- -- Providertwo,Providertwo MARTINSBURG VAMC
01 NOV 2011 @0802 -- PRIMARY CARE/MEDICINE OBESITY, UNSPECIFIED ICD9 278.00 with Provider Comments Obesity in Diabetes -- -- Providertwo,Providertwo MARTINSBURG VAMC
IHE Encounter Template Text not used by VA TESTER,JOHN G POST,WALTER Providertwo,Providertwo Providertwo,Providertwo
History of Procedures
Department of Veterans Affairs Business Rules for Construction of Procedure Information
Procedures This section contains information for the 25 most recent historical (completed) surgical and radiological procedures for the patient from all VA treatment facilities for which the procedure date was within the last 12 months.
Date Time Procedure Type Qualifiers Description Provider Source
13 DEC 2012 @1005 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE -- Associated Notes: OPERATIVE REPORT,SURGERY OPERATIVE REPORT Providertwo,Providertwo MARTINSBURG VAMC
08 DEC 2012 @1605 RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE ACUTE ABDOMEN SERIES, INCLUDING SUPINE, ERECT, AND/OR DECUBITUS VIEWS, SINGLE VIEW CHEST CPT Modifier PROFESSIONAL COMPONENT CPT Modifier REPEAT PROCEDURE BY SAME PHYSICIAN RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE ACUTE ABDOMEN SERIES, INCLUDING SUPINE, ERECT, AND/OR DECUBITUS VIEWS, SINGLE VIEW CHEST PROFESSIONAL COMPONENT,REPEAT PROCEDURE BY SAME PHYSICIAN Providertwo,Providertwo MARTINSBURG VAMC
06 DEC 2012 @1806 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS -- RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS Providerone,Providerone MARTINSBURG VAMC
04 DEC 2012 @1824 RADIOLOGIC EXAMINATION, HIP, UNILATERAL; COMPLETE, MINIMUM OF 2 VIEWS -- RADIOLOGIC EXAMINATION, HIP, UNILATERAL; COMPLETE, MINIMUM OF 2 VIEWS Providertwo,Providertwo MARTINSBURG VAMC
23 SEP 2012 @1030 RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS -- RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS Unknown MARTINSBURG VAMC
23 JUN 2012 @1033 BONE AND/OR JOINT IMAGING; THREE PHASE STUDY -- BONE AND/OR JOINT IMAGING; THREE PHASE STUDY Providertwo,Providertwo MARTINSBURG VAMC
23 AUG 2012 @1024 RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR VIEW -- RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR VIEW Unknown MARTINSBURG VAMC
Providerone, Providerone BLANCO,JOHN L BLANCO,JOHN L Unknown Unknown