ESRD Patient Care Document
Eve Betterhalf
Patient Identifiers
XXXXX2222 United States Social Security Number
About
Date of Birth
May 1, 1975
Sex
Female
Race
White
Ethnicity
Not Hispanic or Latino
Contact
Primary Home
2222 Home Street
Beaverton, OR
97867, US
Tel
+1(555)555-2003
Emergency Contact
Boris Betterhalf
Contact
Primary Home
2222 Home Street
Beaverton, OR
97867, US
Tel
+1(555)555-2008
Next of Kin
Boris Betterhalf
Contact
Primary Home
2222 Home Street
Beaverton, OR
97867, US
Tel
+1(555)555-2008
Service Event
Patricia Primary, M.D. of The DoctorsTogether Physician Group
May 1, 1975 - August 15, 2013
Author
Patricia Primary, M.D.
Contact
1004 Healthcare Drive
Portland, OR
99123, US
Tel
+1(555)555-1004
Informant
Harold Hippocrates, M.D. of The DoctorsApart Physician Group
Contact
1007 Healthcare Drive
Portland, OR
99123, US
Tel
+1(555)555-1003
Informant
Patrick Pump, M.D. of The DoctorsApart Physician Group
Contact
1027 Health Drive
Portland, OR
99123, US
Tel
+1(555)555-1027
Information Recipient
Sara Specialize, M.D.
Legal authenticator
Patricia Primary, M.D. signed at August 15, 2013, 22:36
Contact
1004 Healthcare Drive
Portland, OR
99123, US
Tel
+1(555)555-1004
Dialysis Access Sites
| Type | Status | Location | Date |
|---|---|---|---|
| Arteriovenous Fistula (with 2 needles) | Active | Arm | Jan 1, 2016 |
Plan of Treatment Section
Dialysis Prescription
Instructions
Dialysis Access
Medications Administered
Dialysate
| As-of Date | Prescribed Dry Weight | Primary Setting |
|---|---|---|
| 2015-02-06 | 62 kg | Outpatient Hemodialysis Clinic |
| Modality | Duration | Frequency | Dialyzer | Blood Flow Rate |
|---|---|---|---|---|
| Conventional Hemodialysis | 4 hours | 4 times/week | Fresinius FX 80 | 450 mL/min |
| Type | Location | Priority |
|---|---|---|
| Arteriovenous fistula only (with 2 needles) | Primary |
| Substance | Method | Route | Dose | Instructions |
|---|---|---|---|---|
| Heparin Sodium | Bolus | IVP | 0.25 mL |
| Calcium Level | Potassium Level | Sodium Level | Bicarbonate Level |
|---|---|---|---|
| 2.25 mEq/L | 2.0 mEq/L | 138 mEq/L | 36 mEq/L |
Procedures Section
Conventional Hemodialysis
| Date | BP Pre | BP Post | Weight Pre (kg) | Weight Post (kg) | Duration (hr) | Start Time | End Time | BFR | Dialyzer | Vascular Access | Anticoagulant Administered | Additional Medications |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2 Feb, 2016 | 202/85 Sit | 179/70 Sit | 73.2 | 72.5 | 3:49 | 08:04 | 11:54 | 407 | Fresenius FX 80 | Left Arm Arteriovenous Fistula | 3600 Units, Heparin | |
| 3 Feb, 2016 | 200/87 Sit | 161/73 Sit | 73.5 | 72.6 | 3:48 | 07:53 | 11:41 | 415 | Fresenius FX 80 | Left Arm Arteriovenous Fistula | 3300 Units, Heparin | |
| 4 Feb, 2016 | 183/83 Sit | 183/71 | 74.3 | 73.1 | 3:46 | 08:15 | 12:03 | 410 | Fresenius FX 80 | Left Arm Arteriovenous Fistula | 3200 Units, Heparin |
Problems Section
Other Problems
| Chronic Kidney Disease Stage | Date Observed |
|---|---|
| Stage 4 | February 22, 2016 |
Active Concerns
- Problem #1
- Pneumonia (onset July 3, 2013; resolution Aug 14, 2013) [authored Aug 14, 2013]
Transplant Waitlist Section
| Organ | Listed Facility | Last Updated | Status |
|---|---|---|---|
| Kidney | Fake Facility 123 | 5 February, 2016 | Active |
ALLERGIES AND ADVERSE REACTIONS
| Substance | Reaction |
|---|---|
| Penicillin | Nausea |
| Codeine | Wheezing |
MEDICATIONS
| Medication | Directions | Start Date | Status | Indications | Fill Instructions |
|---|---|---|---|---|---|
| Proventil 0.09 MG/ACTUAT inhalant solution | 2 puffs q6 hours PRN wheezing | Jan 3, 2011 | Active | Asthma | Generic Substitition Allowed |
| Atenolol 25 MG Oral Tablet | 1 every 12 hours Orally | Mar 18, 2012 | Active | Hypertension | -none- |
RESULTS
| Result Type | Result Value | Relevant Reference Range | Interpretation | Date |
|---|---|---|---|---|
| Hemoglobin | 13.2 g/dL | Normal range for women is 12.0 to 15.5 grams per deciliter | Normal | 03/19/2008 |
| Leukocytes | 6.7 10*9/L | Normal white blood cell count range 3.5-10.5 billion cells/L | Normal | 03/19/2008 |
| Platelets | 123 10*9/L | Normal white blood cell count range 3.5-10.5 billion cells/L | Low | 03/19/2008 |
| Hematocrit | 35.3 % | Normal hematocrit range for female: 34.9-44.5 percent | Normal | 03/19/2008 |
| Erythrocytes | 4.21 10*12/L | Normal red blood cell count range 3.90-5.03 trillion cells/L | Normal | 03/19/2008 |
| Urea nitrogen, Serum | Pending | Pending | Pending | March 20, 2008 |
SOCIAL HISTORY
| Social History Observation | Description | Dates Observed |
|---|---|---|
| Current Smoking Status | Former smoker | September 10, 2012 |
| Tobacco Use | Moderate cigarette smoker, 10-19/day | February, 2009 - February, 2011 |
| Alcoholic drinks per day | 12 | Since February, 2012 |
VITAL SIGNS
| Date / Time: | Sept 10, 2012 | Sept 1, 2011 |
|---|---|---|
| Height | 177 cm | 177 cm |
| Weight | 86 kg | 88 kg |
| Blood Pressure | 132/88 | 128/80 |
Signed
Patricia Primary, M.D. at August 15, 2013, 22:15
Contact
1004 Healthcare Drive
Portland, OR
99123, US
Tel
+1(555)555-1004
Document maintained by
Good Health HIE
Contact
Work Place
1009 Healthcare Drive
Portland, OR
99123, US
Tel
+1(555)555-1009
Entered by
Ellen Enter
Contact
1007 Healthcare Drive
Portland, OR
99123, US
Tel
+1(555)555-1050
Document Information
| Document Identifier | Document Created |
|---|---|
| OID: B901D20A-B5C6-11E5-88BC-16106D37453F | August 15, 2013, 10:30 |