diff --git a/Veterans Affairs Blue Button CDA b/Veterans Affairs Blue Button CDA new file mode 100644 index 0000000..6ba02c5 --- /dev/null +++ b/Veterans Affairs Blue Button CDA @@ -0,0 +1,10563 @@ + + + + + + + + + + + + + + Department of Veterans Affairs Health Summary + + + + + + + + + + + + + 123 ANYWHERE RDAPT 123 + WASHINGTON + DC + 20420 + + + + + + + + ONEA + MHVTESTVETERAN + + + + + + + + + + + + MALE + + + + + DIVORCED + + + + + + WHITE + + + WHITE + + + + NOT HISPANIC OR LATINO + + + + + + + + + + + + + + + + + + + + + + + Department of Veterans Affairs + + + + + + Department of Veterans Affairs + + + + + + + + + + + + + Department of Veterans Affairs + + + + + 810 Vermont Avenue NW + Washington + DC + 20420 + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + + + + +
+ + + + + Allergies Section + + + + This section contains Allergies on record with VA for the + patient. The data comes from all VA treatment facilities. It does + not list allergies that were removed or entered in error. Some + allergies may be reported in the Immunization section. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
AllergenEvent DateEvent TypeReaction(s)SeveritySource
Assessment Not Done
Assessment Not Done
+ TERAZOSIN + Jun 03, 2011 + Propensity to adverse reactions to drug + + + + DIZZINESS + + + + + + PORTLAND VA MEDICAL CENTER +
+ BACTRIM + Jun 03, 2011 + Propensity to adverse reactions to drug + + + + + + + + + + PORTLAND VA MEDICAL CENTER +
+ TRAMADOL + Jun 03, 2011 + Propensity to adverse reactions to drug + + + + RETENTION OF URINE + + + + + + PORTLAND VA MEDICAL CENTER +
+ TRIMETHOPRIM + Jun 03, 2011 + Propensity to adverse reactions to drug + + + + + + + + + + PORTLAND VA MEDICAL CENTER +
+ IMIPRAMINE + Dec 07, 2012 + Propensity to adverse reactions to drug + + + + ANAPHYLAXIS + + + + SEVERE + + PORTLAND VA MEDICAL CENTER +
+ TETRACYCLINE + Jan 15, 2016 + Propensity to adverse reactions to drug + + + + ANAPHYLAXIS + + + + SEVERE + + PORTLAND VA MEDICAL CENTER +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DRUG + + + + + + + + + + + + + TERAZOSIN + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DRUG + + + + + + + + + + + + + BACTRIM + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DRUG + + + + + + + + + + + + + TRAMADOL + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DRUG + + + + + + + + + + + + + TRIMETHOPRIM + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DRUG + + + + + + + + + + + + + IMIPRAMINE + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DRUG + + + + + + + + + + + + + TETRACYCLINE + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + + + + Vital Signs Section + + + + This section contains inpatient and outpatient Vital Signs on + record at VA for the patient. The data comes from all VA + treatment facilities. It includes 12 months of data, with a + maximum of the 10 most recent sets of vitals. If more than one + set of vitals was taken + on the same date, only the most recent set is populated for that + date. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Date/TimeTemperaturePulseBlood PressureRespiratory RateSP02PainHeightWeightBody Mass IndexSource
Jan 15, 2016, 07:17 AM101.3 F110 /min155/100 mm[Hg]22 /min100 %2 73 in190 lb25 + PORTLAND VA MEDICAL CENTER +
Jan 15, 2016, 07:16 AM95.9 F80 /min120/80 mm[Hg]16 /min99 %0 72 in180 lb24 + PORTLAND VA MEDICAL CENTER +
+ + Vital Sign Observation Text + Not Available + + + + + + + + + + + + + + + + + + + + + + + HEIGHT + + + + + + + + + + + + + + + + + + + + + + + + + + PULSE + + + + + + + + + + + + + + + + + + + + + + + + + + PAIN + + + + + + + + + + + + + + + + + + + + + + + + + + PULSE OXIMETRY + + + + + + + + + + + + + + + + + + + + + + + + + + RESPIRATION + + + + + + + + + + + + + + + + + + + + + + + + + + TEMPERATURE + + + + + + + + + + + + + + + + + + + + + + + + + + WEIGHT + + + + + + + + + + + + + + + + + + + + + + + + + + SYSTOLIC BLOOD PRESSURE + + + + + + + + + + + + + + + + + + + + + + + + + + DIASTOLIC BLOOD PRESSURE + + + + + + + + + + + + + + + + + + + + + + + + + + BMI + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + HEIGHT + + + + + + + + + + + + + + + + + + + + + + + + + + PULSE + + + + + + + + + + + + + + + + + + + + + + + + + + PAIN + + + + + + + + + + + + + + + + + + + + + + + + + + PULSE OXIMETRY + + + + + + + + + + + + + + + + + + + + + + + + + + RESPIRATION + + + + + + + + + + + + + + + + + + + + + + + + + + TEMPERATURE + + + + + + + + + + + + + + + + + + + + + + + + + + WEIGHT + + + + + + + + + + + + + + + + + + + + + + + + + + SYSTOLIC BLOOD PRESSURE + + + + + + + + + + + + + + + + + + + + + + + + + + DIASTOLIC BLOOD PRESSURE + + + + + + + + + + + + + + + + + + + + + + + + + + BMI + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + + + + Problem List + + + + This section contains a list of Problems/Conditions known to VA + for the patient. It includes both active and inactive + problems/conditions. The data comes from all VA treatment + facilities. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
ProblemStatusProblem CodeDate of OnsetDate of ResolutionComment(s)ProviderSource
+ Congestive heart failure (SCT 42343007) + + Active + + 42343007 + + + + + + + No comments entered for problem. + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Wolff-Parkinson-White pattern (SCT 74390002) + + Active + + 74390002 + + + + + + + No comments entered for problem. + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Mild cognitive impairment (SCT 386805003) + + Active + + 386805003 + + + + + + + + Jan 16, 2013 +Entered By: DOUGLAS,DAVID M +Comment: INDEPENDENT IN ADLs AND IADLs + + + Dec 10, 2012 +Entered By: DOUGLAS,DAVID M +Comment: this is only a test + + + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Diabetes with neurological Manifestations, type i [Juvenile type], not stated as (ICD-9-CM 250.61) + + Active + + 421468001 + + + + + + + No comments entered for problem. + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Hyperlipidemia (ICD-9-CM 272.4) + + Active + + 272.4 + + + + + + + No comments entered for problem. + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Posttraumatic Stress Disorder (ICD-9-CM 309.81) + + Active + + 47505003 + + + + + + + + Feb 11, 2013 +Entered By: DOUGLAS,DAVID M +Comment: comment #3 + + + Feb 11, 2013 +Entered By: DOUGLAS,DAVID M +Comment: Comment #2 + + + Feb 11, 2013 +Entered By: DOUGLAS,DAVID M +Comment: comment #1 + + + Jan 16, 2013 +Entered By: DOUGLAS,DAVID M +Comment: AWAITING A COMP AND PEN EXAM + + + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ TRAUMATIC BRAIN INJURY (ICD-9-CM 799.9) + + Active + + 799.9 + + + + + + + No comments entered for problem. + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Lack of Housing (ICD-9-CM V60.0) + + Inactive + + 160701002 + + + + Dec 10, 2012 + + + No comments entered for problem. + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + 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 + + + + + + + + + + + + + + + + + + + + + INACTIVE + + + + + + + + + + + + + + + + + + + + +
+ + + + +
+ + + + + Advance Directives + + + This section contains ALL of a patient's completed or amended + VA Advance and Rescinded Directives. Entries below indicate that + a directive exists for the patient, but an actual copy is not + included with this document. + + + + + + + + + + + + + + + + + + +
DateAdvance DirectivesProviderSource
Jan 24, 2013 + ADVANCE DIRECTIVE + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + 810 Vermont Avenue NW Washington, DC 20420 + + + + + DOUGLAS,DAVID M + + + + + + + + + + +
+ + + +
+ + + + + Medications Section + + + + This section contains Prescription and Non-Prescription + Medications on record at VA for the patient. Data comes from all + VA treatment facilities. It shows all medications dispensed + within the last 15 months. The list includes the prescription + status as active or non-active. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
MedicationStatusQuantityOrder NumberOrder ExpirationOrdering ProviderRx NumberLast FilledSigSource
+ FISH OIL CAP/TAB + + Active + + + + 39674082 + + + + WOODS,SUSAN S + + + + + + TAKE 1 CAP/TAB BY MOUTH EVERY DAY + + PORTLAND VA MEDICAL CENTER +
+ GINKGO EXT 60MG TAB + + Active + + + + 39674096 + + + + WOODS,SUSAN S + + + + + + TAKE SMALL AMOUNT BY MOUTH EVERY DAY + + PORTLAND VA MEDICAL CENTER +
+ KAVA CAP/TAB + + Active + + + + 41437440 + + + + DOUGLAS,DAVID M + + + + + + TAKE 1 CAP/TAB BY MOUTH EVERY DAY + + PORTLAND VA MEDICAL CENTER +
+ LISINOPRIL 5MG TAB + + Active + + + + 41762366 + + + + DOUGLAS,DAVID M + + + + + + TAKE ONE-HALF TABLET BY MOUTH EVERY DAY + + PORTLAND VA MEDICAL CENTER +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ACTIVE + + + + + + + + + + OTC + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ACTIVE + + + + + + + + + + OTC + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ACTIVE + + + + + + + + + + OTC + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ACTIVE + + + + + + + + + + OTC + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + + + Encounters Section + + + This + section contains a list of completed VA Outpatient Encounters for + the patient and a list of Discharge Summaries, Consult Notes, and + History & Physical Notes for the patient. The data comes from + all VA treatment facilities. +
+
+ + + The list of VA Outpatient Encounters shows the 150 most + recent Encounter dates within the last 36 months. Each VA + Outpatient Encounter may also include several notes with the + complete note text. There is a limit of 10 notes for each + Encounter. Follow-up visits related to the VA Encounter are not + included. The data comes from all VA treatment facilities. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Date/TimeEncounter TypeEncounter DescriptionReasonProviderSource
Jan 19, 2016, 07:45 AM + CARDIOLOGY STRESS OUTPT-4A103 VISIT + + CARDIAC STRESS TEST/ETT + + + + + + PORTLAND VA MEDICAL CENTER +
Jan 19, 2016, 07:15 AM + ECHOCARDIOGRAM 4A-103 VISIT + + CARDIOLOGY + + + + + + PORTLAND VA MEDICAL CENTER +
Jan 15, 2016, 10:00 AM + OFFICE/OUTPATIENT VISIT EST + + NUTRITION/DIETETICS-GROUP + + CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE ICD9 I50.22 with Provider Comments: Congestive heart failure (SCT 42343007) + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
Jun 23, 2015, 06:02 AM + ZZC&P PSY DOUGLAS-7C151 VISIT + + MENTAL HEALTH CONSULTATION + + EFFECTS OF RADIATION, UNSPECIFIED ICD9 990. with Provider Comments: Radiation-induced disorder (SNOMED CT 85983004) + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ + The list of Progress Notes includes the 10 most recent notes for each Outpatient Encounter. The data comes from all VA treatment facilities. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Date/TimeEncounter NoteProviderSource
+ Jan 15, 2016, 07:22 AM + + MENTAL HEALTH OUTPATIENT NOTE : + LOCAL TITLE: MHD - INDIVIDUAL NOTE +STANDARD TITLE: MENTAL HEALTH OUTPATIENT NOTE +DATE OF NOTE: JAN 15, 2016@07:22 ENTRY DATE: JAN 15, 2016@07:22:46 + AUTHOR: DOUGLAS,DAVID M EXP COSIGNER: + URGENCY: STATUS: COMPLETED + +This is only a test + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 13:31 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Jan 15, 2016, 07:26 AM + + C & P EXAMINATION NOTE : + LOCAL TITLE: C&P AID AND ATTENDANCE OR HOUSEBOUND EXAM +STANDARD TITLE: C & P EXAMINATION NOTE +DATE OF NOTE: JAN 15, 2016@07:26 ENTRY DATE: JAN 15, 2016@07:26:54 + AUTHOR: DOUGLAS,DAVID M EXP COSIGNER: + URGENCY: STATUS: COMPLETED + +CLAIMANT'S NAME: + +DATE OF EXAMINATION: + +1. Complete Diagnosis: + +2. Can patient walk unaided? YES/NO-If no, please describe limitation: + +3. Is the patient restricted in ability to feed, bathe, and dress self? +YES/NO- +If restricted, please describe the restrictions: + +4. Is the patient permanently bedridden? YES/NO-If yes, which condition +requires the patient to remain in bed? + +5. Is the claimant blind? YES/NO-If yes, what is the best corrected central +visual acuity? + +6. Can the patient leave home without attendance? YES/NO-If no, please +describe +the extent to which the claimant is housebound and under what circumstances the +patient is able to leave home or immediate premises: + +7. Does the claimant require nursing home care? YES/NO-If no, please describe +the kind of care the patient requires (if any is required): + +8. Please set forth all other pathology (including effects of advancing age, +dizziness, loss of memory, poor balance, etc.) pertinent to the question of +whether the patient is housebound or in need of the regular aid and attendance +of +another person: + +9. Is Claimant competent? YES/NO-If no, please describe reasons: + +I CERTIFY THE ABOVE INFORMATION IS TRUE AND CORRECT. + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 07:34 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Jan 15, 2016, 07:28 AM + + PRIMARY CARE ATTENDING NOTE : + LOCAL TITLE: PC - ATTENDING +STANDARD TITLE: PRIMARY CARE ATTENDING NOTE +DATE OF NOTE: JAN 15, 2016@07:28 ENTRY DATE: JAN 15, 2016@07:28:38 + AUTHOR: DOUGLAS,DAVID M EXP COSIGNER: + URGENCY: STATUS: COMPLETED + +THIS IS A TEST + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 07:34 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Jan 15, 2016, 07:28 AM + + PHYSICAL THERAPY NOTE : + LOCAL TITLE: PHYSICAL THERAPY - DAILY NOTE +STANDARD TITLE: PHYSICAL THERAPY NOTE +DATE OF NOTE: JAN 15, 2016@07:28 ENTRY DATE: JAN 15, 2016@07:29:10 + AUTHOR: DOUGLAS,DAVID M EXP COSIGNER: + URGENCY: STATUS: COMPLETED + +this is a test + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 07:34 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Jan 15, 2016, 07:29 AM + + AGREEMENT : + LOCAL TITLE: COORDINATED CARE HEALTH CARE AGREEMENT +STANDARD TITLE: AGREEMENT +DATE OF NOTE: JAN 15, 2016@07:29 ENTRY DATE: JAN 15, 2016@07:30:18 + AUTHOR: DOUGLAS,DAVID M EXP COSIGNER: + URGENCY: STATUS: COMPLETED + +this is a test + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 07:34 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ + + The list of Consult Notes includes the 20 most recent + notes within the last 24 months. The data comes from all VA + treatment facilities. + + + + + + + + + + + + + + + + + + + + + + +
Date/TimeEncounter NoteProviderSource
+ Jan 15, 2016, 07:41 AM + + + LOCAL TITLE: RHEUMATOLOGY - CONSULT +STANDARD TITLE: RHEUMATOLOGY CONSULT +DATE OF NOTE: JAN 15, 2016@07:41 ENTRY DATE: JAN 15, 2016@07:41:40 + AUTHOR: DOUGLAS,DAVID M EXP COSIGNER: + URGENCY: STATUS: COMPLETED + +idiopathic auto-immune exocrinopathy + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 07:42 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Jan 15, 2016, 07:40 AM + + + LOCAL TITLE: CARDIOLOGY - CONSULT +STANDARD TITLE: CARDIOLOGY CONSULT +DATE OF NOTE: JAN 15, 2016@07:40 ENTRY DATE: JAN 15, 2016@07:41:08 + AUTHOR: DOUGLAS,DAVID M EXP COSIGNER: + URGENCY: STATUS: COMPLETED + +this is a test + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 07:41 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ + The list of History & Physical (H&P) Notes + includes the 20 most recent notes within the last 24 months. The + data comes from all VA treatment facilities. + + + + + + + + + + + + + + + + + + + + + + +
Date/TimeEncounter NoteProviderSource
+ Jan 15, 2016, 07:45 AM + + HISTORY & PHYSICAL : + LOCAL TITLE: ICU - MED - HISTORY & PHYSICAL +STANDARD TITLE: INTERNAL MEDICINE H & P NOTE +DATE OF NOTE: JAN 15, 2016@07:45 ENTRY DATE: JAN 15, 2016@07:45:47 + AUTHOR: DOUGLAS,DAVID M EXP COSIGNER: + URGENCY: STATUS: COMPLETED + +test + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 07:45 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ Jan 15, 2016, 07:44 AM + + HISTORY & PHYSICAL : + LOCAL TITLE: INPAT - MED - HIST&PHYS +STANDARD TITLE: INTERNAL MEDICINE H & P NOTE +DATE OF NOTE: JAN 15, 2016@07:44 ENTRY DATE: JAN 15, 2016@07:45:07 + AUTHOR: DOUGLAS,DAVID M EXP COSIGNER: + URGENCY: STATUS: COMPLETED + +ID: ONE A MHVTESTVETERAN is a 67 year old MALE + + PRIMARY CARE PROVIDER: Unknown + ASSOCIATE PROVIDERS: + + _______________________________________________________ + CC: MHVTESTVETERAN,ONE A presented with a chief complaint of + + HISTORY OF PRESENT ILLNESS: + + + + PERTINENT ED COURSE: + + + + PAST MEDICAL HISTORY: + 1. + 2. + 3. + + + REVIEW OF SYSTEMS: + + SOCIAL HISTORY: + + NEXT OF KIN/FAMILY CONTACTS: + + HABITS: + + FAMILY HISTORY: + + _______________________________________________________ +MEDICATION HISTORY + + Active Outpatient Medications + + Active Outpatient Medications (including Supplies): + + Outpatient Medications Status + ======================================================================== + = + 1) ACETAMINOPHEN TAB TAKE 325-650MG BY MOUTH EVERY 4 TO PENDING + 6 HOURS AS NEEDED *PATIENTS WITHOUT LIVER DISEASE, + MAXIMUM DOSE IS 4 GM/DAY OF ACETAMINOPHEN. + 2) FUROSEMIDE 20MG TAB TAKE ONE-HALF TABLET BY MOUTH PENDING + EVERY DAY + + Non-VA Medications Status + ======================================================================== + = + 1) Non-VA FISH OIL CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE + 2) Non-VA GINKGO BILOBA SMALL AMOUNT MOUTH EVERY DAY ACTIVE + 3) Non-VA KAVA CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE + 4) Non-VA LISINOPRIL 5MG TAB 2.5MG MOUTH EVERY DAY ACTIVE + + 6 Total Medications + -------------------------------------- + + Active/Pending/Expired Medications: + + Active and Recently Expired Outpatient Medications (excluding Supplies): + + Pending Outpatient Medications Status + ======================================================================== + = + 1) ACETAMINOPHEN TAB TAKE 325-650MG BY MOUTH EVERY 4 TO PENDING + 6 HOURS AS NEEDED *PATIENTS WITHOUT LIVER DISEASE, + MAXIMUM DOSE IS 4 GM/DAY OF ACETAMINOPHEN. + 2) FUROSEMIDE 20MG TAB TAKE ONE-HALF TABLET BY MOUTH PENDING + EVERY DAY + + Inactive Outpatient Medications Status + ======================================================================== + = + 1) ASPIRIN 325MG EC TAB TAKE ONE TABLET BY MOUTH EVERY EXPIRED + DAY + 2) ASPIRIN 81MG EC TAB TAKE ONE TABLET BY MOUTH EVERY EXPIRED + DAY + + Active Non-VA Medications Status + ======================================================================== + = + 1) Non-VA FISH OIL CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE + 2) Non-VA GINKGO BILOBA SMALL AMOUNT MOUTH EVERY DAY ACTIVE + 3) Non-VA KAVA CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE + 4) Non-VA LISINOPRIL 5MG TAB 2.5MG MOUTH EVERY DAY ACTIVE + + 8 Total Medications + + Remote Medications + + HDRM - Remote Active Meds + + No Active Remote Medications for this patient + + RART - Remote ADR + + No Remote Allergy/ADR Data available for this patient + -------------------------------------- + Medication Reconciliation: + Medications were reviewed with the patient and/or caregiver, and the + above list is accurate, with any exceptions noted. + + ALLERGIES: TERAZOSIN, BACTRIM, TRAMADOL, TRIMETHOPRIM, IMIPRAMINE, +TETRACYCLINE + + _______________________________________________________ + PHYSICAL: + VITALS SIGNS + Blood pressure: 155/100 (01/15/2016 07:17) + Pulse: 110 (01/15/2016 07:17) + Temperature: 101.3 F [38.5 C] (01/15/2016 07:17) + Respirations: 22 (01/15/2016 07:17) + Weight: 190 lb [86.4 kg] (01/15/2016 07:17) + Height: 73 in [185.4 cm] (01/15/2016 07:17) + + EXAM: + General: + HEENT: + Neck: + Chest: + Cardiac: + Abdomen: + Back/Extrem: + GU/Rectal: + Neuro: + Skin: + + _________________________________________________ + LABORATORY DATA: + No WBC in the last 1Y + No HCT in the last 1Y + No MCV in the last 1Y + + +No AUTO DIFF in the past 1Y + + No SODIUM in the last 1Y + No POTASSIUM in the last 1Y + No CHLORIDE in the last 1Y + CO2 N/A + No UREA NITROGEN in the last 1Y + No CREATININE in the last 1Y + + +Cardiac Enzymes last 72 hours: + No Results last 72 hours + + _______________________________________________________ + IMAGING: + + OTHER DATA: + + ______________________________________________ + IMPRESSION: + + + _______________________________________________________ + ASSESMENT AND PLAN: + PROBLEM 1: + + PLAN: + + PROBLEM 2: + + PLAN: + + PROBLEM 3: + + PLAN: + + PROPHYLAXIS ISSUES: + + _______________________________________________________ + CODE STATUS: + + The patient will be staffed with Dr. within 24 hours. + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 07:45 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ + The list of Discharge Summaries includes the 10 most + recent discharges in the last 36 months. The data comes from all + VA treatment facilities. + + + + + + + + + + + + + + + + + +
Date/TimeEncounter NoteProviderSource
+ Jan 15, 2016 + + DISCHARGE SUMMARY : + LOCAL TITLE: Discharge Summary +STANDARD TITLE: DISCHARGE SUMMARY + DICT DATE: JAN 15, 2016@07:48 ENTRY DATE: JAN 15, 2016@07:49:07 + DICTATED BY: DOUGLAS,DAVID M ATTENDING: DOUGLAS,DAVID M + URGENCY: routine STATUS: COMPLETED + +ATTENDING PHYSICIAN: + +PRIMARY CARE PROVIDER AND FACILIITY: + +PRINCIPAL DIAGNOSIS: + +OTHER DIAGNOSES TREATED OR IMPACTING TREATMENT THIS ADMISSION: + + + +PROCEDURES PERFORMED AT THIS HOSPITAL DURING CURRENT ADMISSION: + +SUMMARY: +(ABBREVIATED HPI, PE, AND PERTINENT LABS) + + +HOSPITAL COURSE: + + +FUNCTIONAL STATUS: +(MAY INCLUDE ACTIVITY LEVEL, WORK RESTRICTIONS, OR DIET) + + +DISCHARGE MEDICATIONS: +(INDICATE ADDITIONS OR CHANGES WITH AN ASTERISK) + + +MEDICATIONS THAT HAVE BEEN DISCONTINUED: + + + +CLINICAL ISSUES REQUIRING FOLLOW UP DURING PC PHONE APT: +1. +2. +3. + + +ADDITIONAL FOLLOW UP APPOINTMENTS: +SPECIALTY EXPECTED DATE SCHEDULED(Y/N) POINT OF CONTACT +1. +2. +3. + + +FOLLOW UP LABS INCLUDING PATHOLOGY & MICROBIOLOGY: +TEST ORDERED(Y/N) EXPECTED DATE IF NOT ORDERED +1. +2. +3. + + +FOLLOW UP IMAGING AND PROCEDURES: +PROCEDURE ORDERED(Y/N) EXPECTED DATE IF NOT ORDERED +1. +2. +3. + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 07:49 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
+ + + IHE Encounter Template + Text not used by VA + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + PORTLAND VA MEDICAL CENTER + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + DOUGLAS,DAVID M + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Encounter Diagnosis Type Not Available + + + + + + + + + + + +
+ + + +
+ + + + + Results Section + + + + This section contains the Chemistry and Hematology Lab Results, + Radiology Reports, and Pathology Reports on record with VA for + the patient. The data comes from all VA treatment facilities. + + + + + + + + + + +
Lab Results
+ The included Chemistry/Hematology Results are from the last 24 + months and are limited to the 20 most recent sets of tests. The + data comes form all VA treatment facilities. +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Date/TimeSourceResult TypeResult - UnitInterpretationReference RangeComment
Jan 19, 2016, 08:01 AM + PORTLAND VA MEDICAL CENTER + + ACCESSION + + + + + + + + Specimen Type: BLOOD +Comment: TEST DATA Ordering Provider: David M Douglas MD Report Released Date/Time: Jan 19, 2016@08:14 + Performing Lab: PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131] + 3710 SW US VETERANS HOSPTL RD PORTLAND, OR 97239-2964 + +
+ + + + + WBC + + 4.4�����10*3/uL + + + + 4.4-10.8 + + +
+ + + + + RBC + + 4.30�����10*6/uL + + + + 4.3-5.6 + + +
+ + + + + HGB + + 4.7�����g/dL + + L + + 13-17.4 + + +
+ + + + + HCT + + 4.8�����% + + L* + + 41-51 + + +
+ + + + + MCV + + 52.0�����fl + + L + + 82.0-98.0 + + +
+ + + + + MCH + + 51�����pg + + H + + 28-34.0 + + +
+ + + + + MCHC + + 50�����g/dL + + H + + 33-37 + + +
+ + + + + RDW + + 37.0�����% + + H + + 11.5-14.5 + + +
+ + + + + PLT + + 38�����10*3/uL + + L + + 150-400 + + +
+ + + + + MPV + + 39�����fl + + H + + 7.4-10.4 + + +
+ + + + + LY% + + 22�����% + + + + 15-42 + + +
+ + + + + LY# + + 23�����10*3/uL + + H + + 1.0-4.0 + + +
+ + + + + NE# + + 21�����10*3/uL + + H + + 2.5-7.0 + + +
+ + + + + NE% + + 20�����% + + L + + 44-78 + + +
+ + + + + MO# + + 25�����10*3/uL + + H + + 0.2-1.0 + + +
+ + + + + MO% + + 24�����% + + H + + 3-12 + + +
+ + + + + EO# + + 27�����10*3/uL + + H + + 0-0.5 + + +
+ + + + + BA# + + 28�����10*3/uL + + H + + 0-0.2 + + +
+ + + + + EO% + + 26�����% + + H + + 0-6 + + +
+ + + + + BA% + + 27�����% + + H + + 0-2 + + +
Jan 19, 2016, 08:01 AM + PORTLAND VA MEDICAL CENTER + + ACCESSION + + + + + + + + Specimen Type: PLASMA +Comment: test data Ordering Provider: David M Douglas MD Report Released Date/Time: Jan 19, 2016@08:12 + Performing Lab: PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131] + 3710 SW US VETERANS HOSPTL RD PORTLAND, OR 97239-2964 + +
+ + + + + GLUCOSE + + 125�����mg/dL + + H + + 71-109 + + +
+ + + + + UREA NITROGEN + + 20�����mg/dL + + + + 7-23 + + +
+ + + + + CREATININE + + 4.3�����mg/dL + + H + + 0.8-1.5 + + +
+ + + + + SODIUM + + 119�����mmol/L + + L* + + 131-142 + + +
+ + + + + POTASSIUM + + 6.1�����mmol/L + + H* + + 3.5-5.0 + + +
+ + + + + CHLORIDE + + 94�����mmol/L + + L + + 95-108 + + +
+ + + + + CO2 + + 33�����mmol/L + + H + + 21-32 + + +
+ + + + + CALCIUM + + 9.5�����mg/dL + + + + 8.4-10.4 + + +
+ + + + + PHOSPHATE + + 4.3�����mg/dL + + + + 2.5-4.5 + + +
+ + + + + CHOLESTEROL + + 210�����mg/dL + + + + 1-240 + + +
+ + + + + PROTEIN,TOTAL + + 8.1�����g/dL + + + + 6.5-8.2 + + +
+ + + + + ALBUMIN + + 4.3�����g/dL + + + + 3.4-5.0 + + +
+ + + + + BILIRUBIN, TOTAL + + 1.2�����mg/dL + + H + + 0.2-1.1 + + +
+ + + + + ALKALINE PHOSPHATASE + + 120�����IU/L + + + + 45-129 + + +
+ + + + + SGOT (AST) + + 45�����IU/L + + H + + 14-44 + + +
+ + + + + ANION GAP + + 10�����mmol/L + + + + 10-22 + + +
+ + + + + EGFR + + 60����� + + + + + + +
Oct 06, 2015, 11:05 AM + PORTLAND VA MEDICAL CENTER + + ACCESSION + + + + + + + + Specimen Type: SERUM +Comment: test for mhv Ordering Provider: Bryan G Cunningham MD Report Released Date/Time: Oct 06, 2015@11:05 + Performing Lab: PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131] + 3710 SW US VETERANS HOSPTL RD PORTLAND, OR 97239-2964 + +
+ + + + + jc virus ab + + neg����� + + + + + + +
+ + + + + jc virus ab, index + + neg����� + + + + + + +
+ + + + + jc virus ab, inhibition + + neg����� + + + + + + +
+ + + + + + + + + + + + + + + + +
Radiology Reports
+ The included Radiology Reports are the 20 most recent reports + within the last 24 months. The data comes from all VA + treatment + facilities. +
+ + + + + + + + + + + + + + + + + + + + + + + +
Result Date/TimeResults Type (LOINC)SourceResultProviderStatus
Jan 15, 2016, 09:46 AM + CHEST 2 VIEWS PA&LAT + + PORTLAND VA MEDICAL CENTER + + +MHVTESTVETERAN,ONE A 666-66-1948 DOB-MAR 01, 1948 M +Exm Date: JAN 15, 2016@09:46 +Req Phys: DOUGLAS,DAVID M Pat Loc: FAKE CLINIC AREA 1475 (Req'g L + Img Loc: PDX-RAY-X + Service: Unknown + + + +(Case 2946 COMPLETE) CHEST 2 VIEWS PA&LAT (RAD Detailed) CPT:71020 + Reason for Study: evaluate chf + + Clinical History: + r/o CHF. + + Report Status: Verified Date Reported: + Date Verified: JAN 15, 2016 + Verifier E-Sig: + + Report: + + Impression: + Test patient; no report necessary for dictation; ADMIN complete. + + Primary Diagnostic Code: + +Primary Interpreting Staff: + RONALD J BOUCHER, MD, CHIEF RADIOLOGIST + Verified by transcriptionist for RONALD J BOUCHER, MD +/JDA + + + + BOUCHER,RONALD J + + completed +
+ + + + + + + + + +
Pathology Reports
+ The included Pathology Reports are the 20 most recent reports + within the last 24 months. The data comes from all VA + treatment + facilities. +
+ + + + + + + + + + + + + + + + + + + + + + + +
Result Date/TimeResults Type (LOINC)SourceResultProviderStatus
Jan 15, 2016, 09:58 AM + LR SURGICAL PATHOLOGY REPORT + + PORTLAND VA MEDICAL CENTER + + +Date Spec taken: Jan 15, 2016 09:58 Pathologist:Olga V DANILOVA +Date Spec rec'd: Jan 15, 2016 09:59 Resident: +Date completed: Jan 15, 2016 Accession #: SP 16 16000 +Submitted by: Practitioner:Olga V DANILOVA +------------------------------------------------------------------------------- +Specimen: +BICEPS BRACHII MUSCLE, BIOPSY + *+* SUPPLEMENTARY REPORT HAS BEEN ADDED *+* + *+* REFER TO BOTTOM OF REPORT *+* +Brief Clinical History: +TEST +Preoperative Diagnosis: +TEST +Operative Findings: +TEST +Postoperative Diagnosis: +TEST +GROSS DESCRIPTION: +TEST +MICROSCOPIC EXAM: (Date Spec taken: Jan 15, 2016 09:58) +DIAGNOSIS AFTER MICROSCOPIC DESCRIPTION: +TEST PATIENT + +MUSCLE BIOPSY: +-MUSCLE TISSUE PRESENT. +-FINAL DIAGNOSIS PENDING OHSU CONSULTATION + +Slide(s) reviewed and diagnosis rendered by: + +OLGA DANILOVA, M.D. +STAFF PATHOLOGIST +PATHOLOGY AND LAB MED +Supplementary Report: +=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=-- +Performing Laboratory: +Surgical Pathology Report Performed By: +PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131] +3710 SW US VETERANS HOSPTL RD PORTLAND, OR 97239-2964 + + + + DANILOVA,OLGA V + + completed +
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+ + + + + Immunizations Section + + + This section contains Immunizations on record with VA for the + patient. The data comes from all VA treatment facilities. A + reaction to an immunization may be reported in the allergy + section. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
ImmunizationSeriesDate IssuedReactionComments
+ TD (ADULT) + + + Jan 15, 2016 + NONE + + this is a test CONTRAINDICATION=DO NOT REPEAT THIS VACCINE. +
+ TD(ADULT) UNSPECIFIED FORMULATION + + + Dec 07, 2012 + + + 1234567 +
+ NOVEL INFLUENZA-H1N1-09, ALL FORMULATIONS + + + Dec 07, 2012 + + + Novartis;#10127605;Feb 2010 +
+ NOVEL INFLUENZA-H1N1-09, ALL FORMULATIONS + + + Oct 01, 2012 + + + +
+ PNEUMOCOCCAL, UNSPECIFIED FORMULATION + + + Mar 06, 2011 + + + Inj type: IM, Site:Lt Deltoid +
+ PNEUMOCOCCAL POLYSACCHARIDE PPV23 + + + Mar 06, 2011 + + + Inj type: IM, Site:Lt Deltoid +
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+ + + + History of Procedures + + + + This section contains a list of Surgical Procedures + performed at VA for the patient. + Included are the 25 most recent procedure dates within the last 12 months. + For each surgical procedure, up to 10 notes are also provided. + Data comes from all VA treatment facilities. + + + + + + + + + + + + + + + + + + + + + + +
Date/TimeProcedure TypeProcedure QualifiersProcedure NoteProviderSource
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Clinical Notes
This section contains the 20 most recent Clinical Procedure Notes that have procedure dates within the last 36 months.
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Date/TimeProcedure NoteProviderSource
+ Jan 15, 2016, 07:30 AM + + SURGERY PROCEDURE NOTE : + LOCAL TITLE: GEN SURG - MINOR PROCEDURE NOTE +STANDARD TITLE: SURGERY PROCEDURE NOTE +DATE OF NOTE: JAN 15, 2016@07:30 ENTRY DATE: JAN 15, 2016@07:30:55 + AUTHOR: DOUGLAS,DAVID M EXP COSIGNER: + URGENCY: STATUS: COMPLETED + +test + +/es/ DAVID M. DOUGLAS MD +CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST +Signed: 01/15/2016 07:34 + + + DOUGLAS,DAVID M + + PORTLAND VA MEDICAL CENTER +
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