Example Healthcare Record Are any of the following specifically required or can the address be just text at this location? 100 Bureau Drive Gaithersburg MD 20899 FirstName MiddleName LastName NIST Registry 100 Bureau Drive Gaithersburg MD 20899 Gaithersburg MD Patients Mother Primary Care Provider Dr. Pseudo Physician-1 NIST HL7 Test Laboratory Primary Care Provider Dr. Pseudo Physician-3 NIST HL7 Test Laboratory
Summary Purpose Transfer of care
Insurance Providers
Payer name Policy type / Coverage type Policy ID Covered party ID Policy Holder
Good Health Insurance Extended healthcare / Family Contract Number 1138345 Patient's Mother
Patients Mom Self Health Plan Name
Allergies and Adverse Reactions
Type Substance Reaction Status
Drug Allergy Penicillin Hives Active
Drug Intolerance Aspirin Wheezing Active
Drug Intolerance Codeine Nausea Active
Penicillin Aspirin Duplication of pointer in originalText of Value below Codeine Required by HITSP C-83
Problems
Problem Effective Dates Problem Status
Asthma 1950 Active
Pneumonia Jan 1997 Resolved
Pneumonia Mar 1999 Resolved
Myocardial Infarction Jan 1997 Resolved
Pregnancy Dec 9, 2009 NOT currently pregnant
Surgeries/Procedures
Procedure Date
Total hip replacement, left 1998
Total hip replacement, left IHE Requires reference to go here instead of originalText of code. Good Health Prostheses Company Location of Documentation - URL or other
Medications
Medication Instructions Start Date Status
Albuterol inhalant 2 puffs QID PRN wheezing   Active
Clopidogrel (Plavix) 75mg PO daily   Active
Metoprolol 25mg PO BID   Active
Prednisone (Deltasone) 20mg PO daily Mar 28, 2000 Active
Cephalexin (Keflex) 500mg PO QID x 7 days (for bronchitis) Mar 28, 2000 No longer active
Albuterol inhalant Clopidogrel Plavix Metoprolol Generic Brand This is the text of the Patient Instruction coded in this Act. Note that this instruction is printed in the narrative text of the parent Section and is refereced by the following pointer to it. Reference goes on text element rather than here. This is the only formal "Free Text comment" in this document! Note that ALL such comments must appear in the narrative text of the parent Section and be referenced by the following pointer to it. IHE Requires reference to go here instead of originalText of code. Prednisone Cephalexin Keflex VA/KP ProblemList subset of SNOMED http://evs.nci.nih.gov/ftp1/FDA/ProblemList/
Advance Directives
Directive Description Custodian Status
Resuscitation status Do not resuscitate Good Health Clinic Current and Verified
Pointer in this location recommended by IHE - rather than originalText in Value below Good Health clinic
Immunizations
Vaccine Date Status
Influenza virus vaccine, IM Nov 1999 Completed
Influenza virus vaccine, IM Dec 1998 Completed
Pneumococcal polysaccharide vaccine, IM Dec 1998 Completed
Tetanus and diphtheria toxoids, IM 1997 Refused
Influenza virus vaccine Influenza virus vaccine Unknown Brand Name Unknown Pneumococcal polysaccharide vaccine Brand Name of Material Required-if-Known text to identifyor describe the Immunization Lot Number. Tetanus and diphtheria toxoids Optional Brand Name of Immunization Required-if-Known text to identifyor describe the Immunization Lot Number.
Vital Signs
Date / Time: Nov 14, 1999 April 7, 2000
Height 177 cm 177 cm
Weight 86 kg 88 kg
Blood Pressure 132/86 mmHg 145/88 mmHg
Diagnostic Results
  March 23, 2000 April 06, 2000
Hematology
HGB (M 13-18 g/dl; F 12-16 g/dl) 13.2  
WBC (4.3-10.8 10+3/ul) 6.7  
PLT (135-145 meq/l) 123 (L)  
Chemistry
NA (135-145meq/l)   140
K (3.5-5.0 meq/l)   4.0
CL (98-106 meq/l)   102
HCO3 (18-23 meq/l)   35 (H)
Extract blood for CBC test Extract blood for CBC test. Note that IHE rules require description and reference to go here rather than in originalText of code. See documentationOf in Header M 13-18 g/dl; F 12-16 g/dl http://nist.etc Extract blood for electrolytes tests Extract blood for electrolytes tests. Not IHE rules require description and reference to go here rather than in originalText of code. See documentationOf in Header
Encounters
Encounter Performer Location Date
Checkup Examination Performer Name Good Health Clinic Apr 07, 2000
Checkup Examination IHE Requires reference to go here instead of originalText of code. Performer Name Good Health Clinic
Functional Status
Functional Condition Effective Dates Condition Status
Dependence on cane 1998 Active
Memory impairment 1999 Active
Family history Father (deceased)
Diagnosis Age At Onset
Myocardial Infarction (cause of death) 57
Hypertension 40
Mother (alive)
Diagnosis Age At Onset
Asthma 30
Medical Equipment
Supply/Device Date Supplied
Automatic implantable cardioverter/defibrillator Nov 1999
Total hip replacement prosthesis 1998
Wheelchair 1999
Good Health Prostheses Company
Social History
Social History Element Description Effective Dates
Cigarette smoking 1 pack per day 1947 - 1972
" None 1973 -
Alcohol consumption None 1973 -
1 pack per day None None
Plan of Care
Planned Activity Planned Date
Pulmonary function test April 21, 2000