MU2 Export Summary GA US Adam TOC Everyman Get Well Clinic 1004 Healthcare Dr. practice Portland OR 97005 United States 1004 Healthcare Dr. practice Portland OR 97005 United States Get Well Clinic 1004 Healthcare Dr. practice Portland OR 97005 United States Get Well Clinic 1004 Healthcare Dr. practice Portland OR 97005 United States Nancy Nightingale Samir Khan
Reason for Referral
Reason for Referral Plan Date Provider
Pulmonary function tests Penny Puffer, 1047 Healthcare Drive, , Portland, OR, 97005, 555-555-1049
Allergies and Adverse Reactions
Name Reaction Notes
penicillin G benzathine
Codeine Phosphate
Plan of Treatment
Planned Activity Comments Planned Date Planned Time Plan/Goal
Pulmonary function tests
Weight Loss Plan 1/16/2013 4:24 PM diet and exercise counseling provided during visit
Weight Loss: Goal 1/16/2013 4:24 PM Weight Loss
Asthma Plan 1/16/2013 4:24 PM resources/instructions provided during visit
Asthma: Goal 1/16/2013 4:24 PM Asthma management
Pulmonary function tests Weight Loss Plan Weight Loss: Goal Asthma Plan Asthma: Goal
Medications
Expired
Name Start Date Expiration Date SIG Comments
albuterol sulfate Inhalation HFA Aerosol Inhaler 90 mcg/actuation 7/10/2012 8/9/2012 inhale 2 puffs by inhalation route every 6 hours for 30 days prn wheezing
inhale 2 puffs by inhalation route every 6 hours for 30 days prn wheezing albuterol sulfate Expired -
History Of Immunizations
Name Date Admin Mfg Name Mfg Code Trade Name Lot# Route Inj Vis Given Vis Pub CVX
Influenza 1/16/2013 Adams Laboratories AD Flu-Imune > 12 Years 6516846541 Intramuscular Left Arm 8/15/2012 1/1/2010 88
6516846541 123 Road Carrollton GA 30117 United States Kati Odom 123 Road Carrollton GA 30117 United States
Problem List
Description Status Onset
Costochondritis Active Encounter
Asthma Active 09/25/2011
Costochondritis Active Asthma Active
Vital Signs
Date Time BP-Sys(mm[Hg] BP-Dia(mm[Hg]) HR(bpm) RR(rpm) Temp WT HT BMI BSA BMI Percentile O2 Sat(%)
1/16/2013 4:02:00 PM 150 mmHg 95 mmHg 195 lbs 70 in 27.9793 kg/m² 2.0901 m²
Blood Pressure - Diastolic Blood Pressure - Systolic Body Mass Index Height Weight
Social History
Name Status Comments
Tobacco Never
Tobacco
History of Procedures
Date Ordered Description Order Status Result Status
8/15/2012 12:00 AM Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use Ordered
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Results Summary
Data and Description Results
1/16/2013 3:52 PM Nurse RN Nightingale, Nancy General Practitioner MD Khan, Samir
1/16/2013 4:28 PM CO2 SerPl-sCnc 25.0 mmol/L
RN Nightingale, Nancy MD Khan, Samir
Functional Status Assessment
Functional Condition Type
No Impairment Cognitive
Has no phyical impairment Functional
No Impairment Has no phyical impairment