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2025-03-27 00:00:00
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600
499
General exam at 63 years highlighted stress. Advised on coping strategies and possible mental health referral.
1947-04-28
Thao506
2010-07-12
2010-07-12
11
wellness
162,673,000
General examination of patient (procedure)
136.8
1,446.08
0
null
null
63
null
Stress
null
null
FIRST NAME: Thao506 NOTE: General exam at 63 years highlighted stress. Advised on coping strategies and possible mental health referral. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
601
501
At 66, patient examined for diabetic retinopathy and noted to be out of workforce. Ophthalmology follow-up advised.
1947-04-28
Thao506
2013-07-29
2013-07-29
11
wellness
162,673,000
General examination of patient (procedure)
136.8
1,349.12
892.89
null
null
66
null
Diabetic retinopathy, Not in workforce
null
null
FIRST NAME: Thao506 NOTE: At 66, patient examined for diabetic retinopathy and noted to be out of workforce. Ophthalmology follow-up advised. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
602
503
General exam at 67 showed need for medication review, limited social contact, and severe anxiety. Mental health support suggested.
1947-04-28
Thao506
2014-08-04
2014-08-04
11
wellness
162,673,000
General examination of patient (procedure)
136.8
934.74
629.82
null
null
67
null
Med review due, Limited social contact, Severe anxiety
null
null
FIRST NAME: Thao506 NOTE: General exam at 67 showed need for medication review, limited social contact, and severe anxiety. Mental health support suggested. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
603
505
Comprehensive assessment at 68 including medication reconciliation and screening for anxiety, falls, domestic abuse, and substance use. Diagnosed ischemic heart disease treated with Clopidogrel, Simvastatin, Metoprolol ER, and nitroglycerin. Patient employed full-time.
1947-04-28
Thao506
2015-08-10
2015-08-10
11
wellness
162,673,000
General examination of patient (procedure)
136.8
1,399.86
933.48
null
null
68
HbA1c 6.9 %, Height 157.9 cm, PainScore 3.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 73.0 mm[Hg], SBP 119.0 mm[Hg], HR 88.0 /min, RR 15.0 /min, BloodGlucose 105.4 mg/dL, BloodBUN 15.0 mg/dL, BloodCreatinine 0.6 mg/dL, BloodCalcium 9.5 mg/dL, BloodNa 136.9 mmol/L, BloodK 4.8 mmol/L, BloodChloride 108.1 mmol/L, Total...
IHD, Full-time employed
Clopidogrel 75mg tab, Simvastatin 20mg tab, 24hr Metoprolol 100mg ER tab, NTG 0.4mg/act spray
Med rec, Health/social needs assess, Anxiety assess, Morse fall assess, Domestic abuse screen, Substance use assess, Drug abuse screen, Dental referral
FIRST NAME: Thao506 NOTE: Comprehensive assessment at 68 including medication reconciliation and screening for anxiety, falls, domestic abuse, and substance use. Diagnosed ischemic heart disease treated with Clopidogrel, Simvastatin, Metoprolol ER, and nitroglycerin. Patient employed full-time. ENCOUNTER TYPE: wellness...
604
515
"Referral to cardiology for further evaluation at age 68 due to ongoing cardiac issues."
1947-04-28
Thao506
2015-08-17
2015-08-17
11
ambulatory
185,347,001
Encounter for problem (procedure)
85.55
516.95
413.56
414,545,008
Ischemic heart disease (disorder)
68
null
null
null
Cards referral
FIRST NAME: Thao506 NOTE: "Referral to cardiology for further evaluation at age 68 due to ongoing cardiac issues." ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
605
516
Consultation and coronary angiography performed due to abnormal cardiac imaging. Post-anesthesia care unit admission noted. Multiple referrals made.
1947-04-28
Thao506
2015-08-19
2015-08-19
11
ambulatory
185,347,001
Encounter for problem (procedure)
85.55
1,875.86
1,500.69
414,545,008
Ischemic heart disease (disorder)
68
null
Abn cardiac img
null
Tx consult, Coronary angio, PACU, Service referral, Cards referral
FIRST NAME: Thao506 NOTE: Consultation and coronary angiography performed due to abnormal cardiac imaging. Post-anesthesia care unit admission noted. Multiple referrals made. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 ...
606
521
Dental evaluation revealed dental caries. Underwent scaling, bitewing x-rays, composite restoration, and received oral health education.
1947-04-28
Thao506
2015-08-31
2015-08-31
11
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,536.75
2,829.4
103,697,008
Patient referral for dental care (procedure)
68
null
Dental caries
null
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Dental bitewing, Gingival exam, Dental composite post-fx, Oral health ed
FIRST NAME: Thao506 NOTE: Dental evaluation revealed dental caries. Underwent scaling, bitewing x-rays, composite restoration, and received oral health education. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
607
524
"Percutaneous coronary intervention performed at 68 to address coronary artery disease."
1947-04-28
Thao506
2015-09-07
2015-09-07
11
ambulatory
185,347,001
Encounter for problem (procedure)
85.55
9,341.15
7,472.92
414,545,008
Ischemic heart disease (disorder)
68
null
null
null
PCI
FIRST NAME: Thao506 NOTE: "Percutaneous coronary intervention performed at 68 to address coronary artery disease." ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
608
525
Annual medication review and multiple health screenings conducted. Non-proliferative diabetic retinopathy noted; referred for ophthalmic monitoring.
1947-04-28
Thao506
2016-08-15
2016-08-15
11
wellness
162,673,000
General examination of patient (procedure)
136.8
1,231.33
798.66
null
null
69
HbA1c 6.9 %, Height 157.9 cm, PainScore 1.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 63.0 mm[Hg], SBP 106.0 mm[Hg], HR 82.0 /min, RR 16.0 /min, BloodGlucose 108.9 mg/dL, BloodBUN 19.5 mg/dL, BloodCreatinine 0.6 mg/dL, BloodCalcium 8.6 mg/dL, BloodNa 137.4 mmol/L, BloodK 4.6 mmol/L, BloodChloride 107.1 mmol/L, Total...
Med review due, NPDR
null
Med rec, Health/social needs assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, Drug abuse screen, Dental referral
FIRST NAME: Thao506 NOTE: Annual medication review and multiple health screenings conducted. Non-proliferative diabetic retinopathy noted; referred for ophthalmic monitoring. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 ...
609
529
"IUD replacement performed at age 69."
1947-04-28
Thao506
2016-08-22
2016-08-22
11
outpatient
308,335,008
Patient encounter procedure (procedure)
142.58
4,052.91
3,242.32
389,095,005
Contraception care (regime/therapy)
69
null
null
null
IUD replacement
FIRST NAME: Thao506 NOTE: "IUD replacement performed at age 69." ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
610
532
Routine dental check-up with scaling and oral health education at 69.
1947-04-28
Thao506
2016-08-29
2016-08-29
11
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
2,673.95
2,139.16
103,697,008
Patient referral for dental care (procedure)
69
null
null
null
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Gingival exam, Oral health ed
FIRST NAME: Thao506 NOTE: Routine dental check-up with scaling and oral health education at 69. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
611
537
At 70, patient not in workforce and experiencing social isolation. Comprehensive assessments and medication review completed.
1947-04-28
Thao506
2017-08-21
2017-08-21
11
wellness
162,673,000
General examination of patient (procedure)
136.8
1,075.86
674.28
null
null
70
HbA1c 6.9 %, Height 157.9 cm, PainScore 1.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 66.0 mm[Hg], SBP 105.0 mm[Hg], HR 62.0 /min, RR 14.0 /min, BloodGlucose 121.9 mg/dL, BloodBUN 19.9 mg/dL, BloodCreatinine 0.7 mg/dL, BloodCalcium 9.5 mg/dL, BloodNa 138.2 mmol/L, BloodK 4.4 mmol/L, BloodChloride 110.7 mmol/L, Total...
Med review due, Not in workforce, Social isolation
null
Med rec, Health/social needs assess, Morse fall assess, Depression screen, Depression screen
FIRST NAME: Thao506 NOTE: At 70, patient not in workforce and experiencing social isolation. Comprehensive assessments and medication review completed. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
612
539
Health needs including substance use and domestic abuse screening done. Patient unemployed and has gingivitis requiring dental care.
1947-04-28
Thao506
2018-08-27
2018-08-27
11
wellness
162,673,000
General examination of patient (procedure)
136.8
996.16
610.52
null
null
71
HbA1c 6.9 %, Height 157.9 cm, PainScore 3.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 59.0 mm[Hg], SBP 100.0 mm[Hg], HR 79.0 /min, RR 13.0 /min, BloodGlucose 114.6 mg/dL, BloodBUN 14.2 mg/dL, BloodCreatinine 0.6 mg/dL, BloodCalcium 9.3 mg/dL, BloodNa 142.4 mmol/L, BloodK 4.0 mmol/L, BloodChloride 102.2 mmol/L, Total...
Med review due, Unemployed, Gingivitis
null
Health/social needs assess, Morse fall assess, Domestic abuse screen, Substance use assess, AUDIT-C assess, Dental referral
FIRST NAME: Thao506 NOTE: Health needs including substance use and domestic abuse screening done. Patient unemployed and has gingivitis requiring dental care. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
613
540
Extensive dental procedures addressing gum disease including surgery, desensitizing treatment, and fluoride application.
1947-04-28
Thao506
2018-09-10
2018-09-11
11
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
4,830.95
3,864.76
66,383,009
Gingivitis (disorder)
71
null
Gum disease
NaF 2.72% oral gel
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Gingival exam, Dental surgery, Dental desensitizing, Gingivectomy, Dental postop care, Dental fluoride, Oral health ed
FIRST NAME: Thao506 NOTE: Extensive dental procedures addressing gum disease including surgery, desensitizing treatment, and fluoride application. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
614
541
At 72, patient screened for multiple health/social issues including depression and substance use; remains employed full-time.
1947-04-28
Thao506
2019-09-02
2019-09-02
11
wellness
162,673,000
General examination of patient (procedure)
136.8
1,150.44
733.94
null
null
72
HbA1c 6.9 %, Height 157.9 cm, PainScore 1.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 61.0 mm[Hg], SBP 102.0 mm[Hg], HR 72.0 /min, RR 14.0 /min, BloodGlucose 110.0 mg/dL, BloodBUN 14.6 mg/dL, BloodCreatinine 0.6 mg/dL, BloodCalcium 9.9 mg/dL, BloodNa 139.8 mmol/L, BloodK 3.9 mmol/L, BloodChloride 110.7 mmol/L, Total...
Full-time employed
null
Med rec, Health/social needs assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, AUDIT-C assess
FIRST NAME: Thao506 NOTE: At 72, patient screened for multiple health/social issues including depression and substance use; remains employed full-time. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
615
548
Screening for anxiety and depression at 73 with ongoing gingivitis. Medication review due.
1947-04-28
Thao506
2020-09-07
2020-09-07
11
wellness
162,673,000
General examination of patient (procedure)
136.8
853.36
496.28
null
null
73
HbA1c 6.9 %, Height 157.9 cm, PainScore 2.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 59.0 mm[Hg], SBP 109.0 mm[Hg], HR 64.0 /min, RR 15.0 /min, BloodGlucose 109.8 mg/dL, BloodBUN 12.6 mg/dL, BloodCreatinine 0.5 mg/dL, BloodCalcium 9.7 mg/dL, BloodNa 138.9 mmol/L, BloodK 5.2 mmol/L, BloodChloride 108.6 mmol/L, Total...
Med review due, Gingivitis
null
Health/social needs assess, Anxiety assess, Depression screen, Depression screen, Dental referral
FIRST NAME: Thao506 NOTE: Screening for anxiety and depression at 73 with ongoing gingivitis. Medication review due. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 N...
616
550
Routine dental care and examination at 73 including scaling and oral health education.
1947-04-28
Thao506
2020-09-21
2020-09-21
11
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,105.35
2,484.28
66,383,009
Gingivitis (disorder)
73
null
null
null
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Dental bitewing, Gingival exam, Oral health ed
FIRST NAME: Thao506 NOTE: Routine dental care and examination at 73 including scaling and oral health education. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN...
617
551
Urgent care visit related to environmental violence. Assessed for anxiety, falls, and depression; patient currently not working.
1947-04-28
Thao506
2021-07-26
2021-07-26
11
urgentcare
702,927,004
Urgent care clinic (environment)
142.58
865.94
506.34
null
null
74
HbA1c 6.9 %, Height 157.9 cm, PainScore 0.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 64.0 mm[Hg], SBP 107.0 mm[Hg], HR 93.0 /min, RR 14.0 /min, BloodGlucose 102.4 mg/dL, BloodBUN 15.3 mg/dL, BloodCreatinine 0.6 mg/dL, BloodCalcium 9.1 mg/dL, BloodNa 142.6 mmol/L, BloodK 3.9 mmol/L, BloodChloride 108.2 mmol/L, Total...
Not in workforce, Enviro violence
null
Health/social needs assess, Anxiety assess, Morse fall assess, Depression screen, Depression screen
FIRST NAME: Thao506 NOTE: Urgent care visit related to environmental violence. Assessed for anxiety, falls, and depression; patient currently not working. ENCOUNTER TYPE: urgentcare REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
618
552
"Vaccine administered at age 74 to boost immunity."
1947-04-28
Thao506
2021-08-02
2021-08-02
11
outpatient
33,879,002
Administration of vaccine to produce active immunity (procedure)
142.58
278.58
222.86
null
null
74
null
null
null
null
FIRST NAME: Thao506 NOTE: "Vaccine administered at age 74 to boost immunity." ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
619
553
Presented with acute viral pharyngitis symptoms; supportive care provided.
1947-04-28
Thao506
2021-08-02
2021-08-02
11
ambulatory
185,345,009
Encounter for symptom (procedure)
85.55
85.55
68.44
195,662,009
Acute viral pharyngitis (disorder)
74
BodyTemp 37.9 Cel
Acute viral pharyngitis
null
null
FIRST NAME: Thao506 NOTE: Presented with acute viral pharyngitis symptoms; supportive care provided. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
620
554
"IUD replacement performed during visit at 74."
1947-04-28
Thao506
2021-08-23
2021-08-30
11
outpatient
308,335,008
Patient encounter procedure (procedure)
142.58
4,681.73
3,745.38
389,095,005
Contraception care (regime/therapy)
74
null
null
null
IUD replacement
FIRST NAME: Thao506 NOTE: "IUD replacement performed during visit at 74." ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
621
555
Comprehensive psychological and health needs assessments performed. Patient employed full-time with ongoing monitoring for anxiety, depression, and safety.
1947-04-28
Thao506
2021-09-13
2021-09-13
11
wellness
162,673,000
General examination of patient (procedure)
136.8
939.86
751.88
null
null
74
HbA1c 6.9 %, Height 157.9 cm, PainScore 0.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 65.0 mm[Hg], SBP 105.0 mm[Hg], HR 69.0 /min, RR 13.0 /min, BloodGlucose 119.0 mg/dL, BloodBUN 9.6 mg/dL, BloodCreatinine 0.6 mg/dL, BloodCalcium 9.6 mg/dL, BloodNa 136.1 mmol/L, BloodK 3.9 mmol/L, BloodChloride 102.7 mmol/L, TotalC...
Full-time employed
null
Med rec, Health/social needs assess, Anxiety assess, Morse fall assess, Domestic abuse screen, Depression screen, Depression screen, PHQ-9 screen
FIRST NAME: Thao506 NOTE: Comprehensive psychological and health needs assessments performed. Patient employed full-time with ongoing monitoring for anxiety, depression, and safety. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 ...
622
562
Hospitalized at 75 for comprehensive care including physical therapy, occupational therapy, speech therapy, and nursing care. Individualized care plan implemented with multidisciplinary support.
1947-04-28
Thao506
2022-05-02
2022-05-23
11
snf
32,485,007
Hospital admission (procedure)
110.92
16,713.67
13,184.54
25,675,004
Patient transfer to skilled nursing facility (procedure)
75
null
null
null
H&P, Initial assess, Indiv care plan, Nursing care, Speech therapy, Nursing care, PT, Nursing care, Nursing care, Nursing care, Nursing care, PT, Nursing care, Nursing care, Nursing care, OT, Nursing care, Nursing care, Nursing care, Nursing care, Speech therapy, Nursing care, OT, Ancillary services, Nursing care, PT, ...
FIRST NAME: Thao506 NOTE: Hospitalized at 75 for comprehensive care including physical therapy, occupational therapy, speech therapy, and nursing care. Individualized care plan implemented with multidisciplinary support. ENCOUNTER TYPE: snf REASON FOR ENCOUNTER: 0 NaN 1 ...
623
578
Health assessment including screening for depression and substance use at 75; medication review due.
1947-04-28
Thao506
2022-09-19
2022-09-19
11
wellness
162,673,000
General examination of patient (procedure)
136.8
860.16
688.12
null
null
75
HbA1c 6.9 %, Height 157.9 cm, PainScore 2.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 63.0 mm[Hg], SBP 106.0 mm[Hg], HR 66.0 /min, RR 16.0 /min, BloodGlucose 114.5 mg/dL, BloodBUN 16.4 mg/dL, BloodCreatinine 0.5 mg/dL, BloodCalcium 9.2 mg/dL, BloodNa 138.8 mmol/L, BloodK 4.3 mmol/L, BloodChloride 103.1 mmol/L, Total...
Med review due
null
Health/social needs assess, Depression screen, Depression screen, Substance use assess, AUDIT-C assess
FIRST NAME: Thao506 NOTE: Health assessment including screening for depression and substance use at 75; medication review due. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
624
586
Presented with viral sinusitis symptoms, treated conservatively.
1947-04-28
Thao506
2022-12-28
2022-12-28
11
ambulatory
185,345,009
Encounter for symptom (procedure)
85.55
85.55
68.44
444,814,009
Viral sinusitis (disorder)
75
null
Viral sinusitis
null
null
FIRST NAME: Thao506 NOTE: Presented with viral sinusitis symptoms, treated conservatively. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
625
587
Routine check-up with medication reconciliation and health/social needs assessment.
1947-04-28
Thao506
2023-01-16
2023-01-16
11
outpatient
185,349,003
Encounter for check up (procedure)
85.55
1,024.61
819.68
null
null
75
HbA1c 6.9 %, Height 157.9 cm, PainScore 3.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 65.0 mm[Hg], SBP 110.0 mm[Hg], HR 86.0 /min, RR 12.0 /min, BloodGlucose 116.5 mg/dL, BloodBUN 10.7 mg/dL, BloodCreatinine 0.8 mg/dL, BloodCalcium 9.1 mg/dL, BloodNa 138.2 mmol/L, BloodK 3.8 mmol/L, BloodChloride 109.0 mmol/L, Total...
null
null
Med rec, Health/social needs assess
FIRST NAME: Thao506 NOTE: Routine check-up with medication reconciliation and health/social needs assessment. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
626
596
At 76, patient screened for anxiety, depression, substance use, and falls. Not currently in workforce and reports stress; medication review needed.
1947-04-28
Thao506
2023-09-25
2023-09-25
11
wellness
162,673,000
General examination of patient (procedure)
136.8
1,439.14
964.9
null
null
76
HbA1c 6.9 %, Height 157.9 cm, PainScore 1.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 60.0 mm[Hg], SBP 108.0 mm[Hg], HR 66.0 /min, RR 13.0 /min, BloodGlucose 114.9 mg/dL, BloodBUN 7.0 mg/dL, BloodCreatinine 0.9 mg/dL, BloodCalcium 9.9 mg/dL, BloodNa 139.3 mmol/L, BloodK 3.9 mmol/L, BloodChloride 106.3 mmol/L, TotalC...
Med review due, Not in workforce, Stress
null
Med rec, Health/social needs assess, Anxiety assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Thao506 NOTE: At 76, patient screened for anxiety, depression, substance use, and falls. Not currently in workforce and reports stress; medication review needed. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 ...
627
603
Health and medication review at 77 including depression and substance use assessments. Patient employed part-time.
1947-04-28
Thao506
2024-09-30
2024-09-30
11
wellness
162,673,000
General examination of patient (procedure)
136.8
1,150.44
733.94
null
null
77
HbA1c 6.9 %, Height 157.9 cm, PainScore 1.0 {score}, Weight 68.3 kg, BMI 27.4 kg/m2, DBP 63.0 mm[Hg], SBP 110.0 mm[Hg], HR 81.0 /min, RR 14.0 /min, BloodGlucose 116.4 mg/dL, BloodBUN 16.0 mg/dL, BloodCreatinine 0.5 mg/dL, BloodCalcium 8.7 mg/dL, BloodNa 137.2 mmol/L, BloodK 5.1 mmol/L, BloodChloride 102.0 mmol/L, Total...
Med review due, Part-time employed
null
Med rec, Health/social needs assess, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Thao506 NOTE: Health and medication review at 77 including depression and substance use assessments. Patient employed part-time. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
628
628
Patient, age 9, presented with chronic sinusitis. No procedures or medications documented at this visit. Plan includes monitoring and symptom management.
1993-05-28
Enrique929
2002-09-26
2002-09-26
12
ambulatory
185,345,009
Encounter for symptom (procedure)
85.55
92.93
0
75,498,004
Acute bacterial sinusitis (disorder)
9
null
Chronic sinusitis
null
null
FIRST NAME: Enrique929 NOTE: Patient, age 9, presented with chronic sinusitis. No procedures or medications documented at this visit. Plan includes monitoring and symptom management. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 ...
629
629
At 18, routine general examination performed. Patient is engaged in higher education and employed full-time. Medication review is due. No acute issues noted.
1993-05-28
Enrique929
2011-07-22
2011-07-22
12
wellness
162,673,000
General examination of patient (procedure)
136.8
704.2
0
null
null
18
null
Med review due, Higher ed, Full-time employed
null
null
FIRST NAME: Enrique929 NOTE: At 18, routine general examination performed. Patient is engaged in higher education and employed full-time. Medication review is due. No acute issues noted. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 ...
630
630
At 19, general examination revealed prediabetes and anemia. Patient also reports social isolation. No procedures or medications documented. Plan to manage conditions and provide social support.
1993-05-28
Enrique929
2012-07-27
2012-07-27
12
wellness
162,673,000
General examination of patient (procedure)
136.8
849.22
0
null
null
19
null
Prediabetes, Anemia, Social isolation
null
null
FIRST NAME: Enrique929 NOTE: At 19, general examination revealed prediabetes and anemia. Patient also reports social isolation. No procedures or medications documented. Plan to manage conditions and provide social support. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 N...
631
631
At age 22, comprehensive evaluation including medication reconciliation and multiple psychosocial assessments performed. Patient reports stress and is currently not in workforce. No medications documented.
1993-05-28
Enrique929
2015-07-31
2015-07-31
12
wellness
162,673,000
General examination of patient (procedure)
136.8
1,490.66
0
null
null
22
HbA1c 6.0 %, Height 181.0 cm, PainScore 1.0 {score}, Weight 78.5 kg, BMI 24.0 kg/m2, DBP 89.0 mm[Hg], SBP 112.0 mm[Hg], HR 76.0 /min, RR 13.0 /min, BloodGlucose 80.1 mg/dL, BloodBUN 19.2 mg/dL, BloodCreatinine 1.3 mg/dL, BloodCalcium 8.8 mg/dL, BloodNa 141.7 mmol/L, BloodK 4.2 mmol/L, BloodChloride 101.1 mmol/L, TotalC...
Not in workforce, Stress
null
Med rec, Health/social needs assess, Anxiety assess, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Enrique929 NOTE: At age 22, comprehensive evaluation including medication reconciliation and multiple psychosocial assessments performed. Patient reports stress and is currently not in workforce. No medications documented. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 ...
632
632
At 25, general examination with social and mental health assessments including depression and substance use screening. Medication review is due. Patient is employed full-time but reports environmental violence exposure.
1993-05-28
Enrique929
2018-08-03
2018-08-03
12
wellness
162,673,000
General examination of patient (procedure)
136.8
785.58
0
null
null
25
HbA1c 6.2 %, Height 181.0 cm, PainScore 3.0 {score}, Weight 83.2 kg, BMI 25.4 kg/m2, DBP 91.0 mm[Hg], SBP 107.0 mm[Hg], HR 85.0 /min, RR 12.0 /min, BloodGlucose 91.1 mg/dL, BloodBUN 8.0 mg/dL, BloodCreatinine 1.3 mg/dL, BloodCalcium 8.8 mg/dL, BloodNa 139.1 mmol/L, BloodK 4.3 mmol/L, BloodChloride 110.2 mmol/L, TotalCO...
Med review due, Full-time employed, Enviro violence
null
Health/social needs assess, Depression screen, Depression screen, Substance use assess, AUDIT-C assess
FIRST NAME: Enrique929 NOTE: At 25, general examination with social and mental health assessments including depression and substance use screening. Medication review is due. Patient is employed full-time but reports environmental violence exposure. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 ...
633
633
Emergency visit for mandible fracture at age 27. Procedures included mandible X-ray, closed reduction, bone immobilization, and orthopedic stabilization. Medications prescribed include acetaminophen/oxycodone and naproxen for pain control.
1993-05-28
Enrique929
2021-04-05
2021-04-05
12
emergency
50,849,002
Emergency room admission (procedure)
146.18
1,871.78
0
263,172,003
Fracture of mandible (disorder)
27
null
Mandible fx
APAP 325mg/Oxycodone 5mg tab, Naproxen Na 220mg tab
Mandible XR, Mandib fx closed reduction, Bone immob, Ortho stabilization
FIRST NAME: Enrique929 NOTE: Emergency visit for mandible fracture at age 27. Procedures included mandible X-ray, closed reduction, bone immobilization, and orthopedic stabilization. Medications prescribed include acetaminophen/oxycodone and naproxen for pain control. ENCOUNTER TYPE: emergency REASON FOR ENCOUNTER: 0 ...
634
634
Post-ER visit dental check up including comprehensive dental cleaning, gingival examination, and fluoride application with oral health education. Prescribed sodium fluoride oral gel.
1993-05-28
Enrique929
2021-04-16
2021-04-16
12
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,105.35
0
263,172,003
Fracture of mandible (disorder)
27
null
null
NaF 2.72% oral gel
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Gingival exam, Dental fluoride, Oral health ed
FIRST NAME: Enrique929 NOTE: Post-ER visit dental check up including comprehensive dental cleaning, gingival examination, and fluoride application with oral health education. Prescribed sodium fluoride oral gel. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 ...
635
635
At age 27, dental and oral range of motion exam performed. No abnormal findings documented.
1993-05-28
Enrique929
2021-05-18
2021-05-18
12
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
948.35
82.19
263,172,003
Fracture of mandible (disorder)
27
null
null
null
Oral exam, ROM testing
FIRST NAME: Enrique929 NOTE: At age 27, dental and oral range of motion exam performed. No abnormal findings documented. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
636
636
At 28, patient underwent medication reconciliation and extensive psychosocial and dental assessments. Reports part-time employment, limited social contact, and gingivitis was noted. Referred to dental care.
1993-05-28
Enrique929
2021-08-06
2021-08-06
12
wellness
162,673,000
General examination of patient (procedure)
136.8
1,075.86
0
null
null
28
HbA1c 6.2 %, Height 181.0 cm, PainScore 4.0 {score}, Weight 86.8 kg, BMI 26.5 kg/m2, DBP 94.0 mm[Hg], SBP 112.0 mm[Hg], HR 70.0 /min, RR 13.0 /min, BloodGlucose 82.8 mg/dL, BloodBUN 9.8 mg/dL, BloodCreatinine 1.4 mg/dL, BloodCalcium 9.2 mg/dL, BloodNa 140.4 mmol/L, BloodK 4.5 mmol/L, BloodChloride 107.1 mmol/L, TotalCO...
Part-time employed, Limited social contact, Gingivitis
null
Med rec, Health/social needs assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, AUDIT-C assess, Dental referral
FIRST NAME: Enrique929 NOTE: At 28, patient underwent medication reconciliation and extensive psychosocial and dental assessments. Reports part-time employment, limited social contact, and gingivitis was noted. Referred to dental care. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 ...
637
637
Dental follow-up at 28 with cleaning and fluoride treatment. Continued oral health education and NaF 2.72% oral gel prescribed.
1993-05-28
Enrique929
2021-08-20
2021-08-20
12
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,105.35
0
66,383,009
Gingivitis (disorder)
28
null
null
NaF 2.72% oral gel
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Gingival exam, Dental fluoride, Oral health ed
FIRST NAME: Enrique929 NOTE: Dental follow-up at 28 with cleaning and fluoride treatment. Continued oral health education and NaF 2.72% oral gel prescribed. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
638
638
At 30, patient presented with acute viral pharyngitis. Symptomatic treatment recommended.
1993-05-28
Enrique929
2024-03-21
2024-03-21
12
ambulatory
185,345,009
Encounter for symptom (procedure)
85.55
85.55
0
195,662,009
Acute viral pharyngitis (disorder)
30
BodyTemp 37.4 Cel
Acute viral pharyngitis
null
null
FIRST NAME: Enrique929 NOTE: At 30, patient presented with acute viral pharyngitis. Symptomatic treatment recommended. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
639
639
At age 31, comprehensive exam including medication reconciliation and multiple psychosocial assessments. Patient has hypertension managed with HCTZ 25mg. Medication review is due. Referred to dental care.
1993-05-28
Enrique929
2024-08-09
2024-08-09
12
wellness
162,673,000
General examination of patient (procedure)
136.8
1,205.06
0
null
null
31
HbA1c 6.3 %, Height 181.0 cm, PainScore 0.0 {score}, Weight 91.5 kg, BMI 27.9 kg/m2, DBP 96.0 mm[Hg], SBP 159.0 mm[Hg], HR 78.0 /min, RR 16.0 /min, BloodGlucose 87.4 mg/dL, BloodBUN 13.8 mg/dL, BloodCreatinine 1.4 mg/dL, BloodCalcium 9.5 mg/dL, BloodNa 139.7 mmol/L, BloodK 3.8 mmol/L, BloodChloride 101.6 mmol/L, TotalC...
HTN, Med review due
HCTZ 25mg tab, HCTZ 25mg tab
Med rec, Health/social needs assess, Anxiety assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, AUDIT-C assess, Dental referral
FIRST NAME: Enrique929 NOTE: At age 31, comprehensive exam including medication reconciliation and multiple psychosocial assessments. Patient has hypertension managed with HCTZ 25mg. Medication review is due. Referred to dental care. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 ...
640
640
Dental check-up at 31 with cleaning, bitewing X-rays, gingival exam, fluoride treatment, and oral health education. NaF 2.72% oral gel prescribed.
1993-05-28
Enrique929
2024-08-23
2024-08-23
12
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,536.75
0
103,697,008
Patient referral for dental care (procedure)
31
null
null
NaF 2.72% oral gel
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Dental bitewing, Gingival exam, Dental fluoride, Oral health ed
FIRST NAME: Enrique929 NOTE: Dental check-up at 31 with cleaning, bitewing X-rays, gingival exam, fluoride treatment, and oral health education. NaF 2.72% oral gel prescribed. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 ...
641
641
Follow-up encounter at 31, no additional findings or interventions documented.
1993-05-28
Enrique929
2024-09-08
2024-09-08
12
ambulatory
390,906,007
Follow-up encounter (procedure)
85.55
85.55
0
59,621,000
Essential hypertension (disorder)
31
DBP 85.0 mm[Hg], SBP 145.0 mm[Hg]
null
null
null
FIRST NAME: Enrique929 NOTE: Follow-up encounter at 31, no additional findings or interventions documented. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
642
642
Follow-up encounter at 31, no additional findings or interventions documented.
1993-05-28
Enrique929
2024-11-07
2024-11-07
12
ambulatory
390,906,007
Follow-up encounter (procedure)
85.55
85.55
0
59,621,000
Essential hypertension (disorder)
31
DBP 86.0 mm[Hg], SBP 146.0 mm[Hg]
null
null
null
FIRST NAME: Enrique929 NOTE: Follow-up encounter at 31, no additional findings or interventions documented. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
643
643
Follow-up encounter at 31, no additional findings or interventions documented.
1993-05-28
Enrique929
2025-01-06
2025-01-06
12
ambulatory
390,906,007
Follow-up encounter (procedure)
85.55
85.55
0
59,621,000
Essential hypertension (disorder)
31
DBP 86.0 mm[Hg], SBP 139.0 mm[Hg]
null
null
null
FIRST NAME: Enrique929 NOTE: Follow-up encounter at 31, no additional findings or interventions documented. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
644
644
Patient presented for routine well child visit at age 17. No procedures or medications administered. Patient reported engagement in risk behaviors and advised on counseling and preventive health.
1922-09-26
Kelley882
1939-11-15
1939-11-15
13
wellness
410,620,009
Well child visit (procedure)
136.8
568.2
0
null
null
17
null
Risk behaviors
null
null
FIRST NAME: Kelley882 NOTE: Patient presented for routine well child visit at age 17. No procedures or medications administered. Patient reported engagement in risk behaviors and advised on counseling and preventive health. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 ...
645
645
At age 18, patient underwent general examination. History includes military service and high school education. No acute findings noted.
1922-09-26
Kelley882
1940-11-20
1940-11-20
13
wellness
162,673,000
General examination of patient (procedure)
136.8
792.52
0
null
null
18
null
Military service, HS education
null
null
FIRST NAME: Kelley882 NOTE: At age 18, patient underwent general examination. History includes military service and high school education. No acute findings noted. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
646
646
At 31 years, patient evaluated with general exam revealing prediabetes. Lifestyle modifications recommended to prevent progression.
1922-09-26
Kelley882
1953-12-09
1953-12-09
13
wellness
162,673,000
General examination of patient (procedure)
136.8
1,450.97
0
null
null
31
null
Prediabetes
null
null
FIRST NAME: Kelley882 NOTE: At 31 years, patient evaluated with general exam revealing prediabetes. Lifestyle modifications recommended to prevent progression. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
647
647
Check-up visit at age 31 noted anemia; further workup and management advised.
1922-09-26
Kelley882
1954-04-07
1954-04-07
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
228.35
137.01
null
null
31
null
Anemia
null
null
FIRST NAME: Kelley882 NOTE: Check-up visit at age 31 noted anemia; further workup and management advised. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
648
648
At age 48, patient admitted for sepsis. Appropriate infection control and supportive care initiated.
1922-09-26
Kelley882
1970-11-11
1970-11-18
13
emergency
185,347,001
Encounter for problem (procedure)
87.71
1,025.09
0
91,302,008
Sepsis (disorder)
48
null
Sepsis
null
null
FIRST NAME: Kelley882 NOTE: At age 48, patient admitted for sepsis. Appropriate infection control and supportive care initiated. ENCOUNTER TYPE: emergency REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
649
649
Patient at 55 years presented with hand osteoarthritis managed with Naproxen 220mg tablets.
1922-09-26
Kelley882
1977-11-27
1977-11-27
13
ambulatory
185,347,001
Encounter for problem (procedure)
85.55
85.55
0
201,834,006
Localized primary osteoarthritis of the hand (disorder)
55
null
Hand OA
Naproxen Na 220mg tab
null
FIRST NAME: Kelley882 NOTE: Patient at 55 years presented with hand osteoarthritis managed with Naproxen 220mg tablets. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
650
650
General exam at 60 years showed diagnosis of Type 2 Diabetes Mellitus. Diabetes management ongoing.
1922-09-26
Kelley882
1982-11-24
1982-11-24
13
wellness
162,673,000
General examination of patient (procedure)
136.8
983.54
0
null
null
60
null
DM2
null
null
FIRST NAME: Kelley882 NOTE: General exam at 60 years showed diagnosis of Type 2 Diabetes Mellitus. Diabetes management ongoing. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
651
651
At 61, hypertriglyceridemia identified during general examination. Diet and lipid management reviewed.
1922-09-26
Kelley882
1983-11-30
1983-11-30
13
wellness
162,673,000
General examination of patient (procedure)
136.8
853.36
0
null
null
61
null
HTG
null
null
FIRST NAME: Kelley882 NOTE: At 61, hypertriglyceridemia identified during general examination. Diet and lipid management reviewed. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
652
652
At age 63, patient evaluated for prostate neoplasm and carcinoma in situ; oncology referral made.
1922-09-26
Kelley882
1985-12-18
1985-12-18
13
ambulatory
185,347,001
Encounter for problem (procedure)
85.55
10,495.5
4,330.91
126,906,006
Neoplasm of prostate (disorder)
63
null
Prostate neoplasm, Prostate CIS
null
null
FIRST NAME: Kelley882 NOTE: At age 63, patient evaluated for prostate neoplasm and carcinoma in situ; oncology referral made. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
653
653
General exam revealed metabolic syndrome at 65; cardiovascular risk reduction steps advised.
1922-09-26
Kelley882
1987-12-23
1987-12-23
13
wellness
162,673,000
General examination of patient (procedure)
136.8
860.16
688.12
null
null
65
null
MetS
null
null
FIRST NAME: Kelley882 NOTE: General exam revealed metabolic syndrome at 65; cardiovascular risk reduction steps advised. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
654
654
Check-up visit at 66 diagnosed ischemic heart disease; ongoing cardiology management.
1922-09-26
Kelley882
1989-07-19
1989-07-19
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
802.11
641.68
null
null
66
null
IHD
null
null
FIRST NAME: Kelley882 NOTE: Check-up visit at 66 diagnosed ischemic heart disease; ongoing cardiology management. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 Na...
655
655
Symptoms related to cardiac status managed with Metoprolol 100mg ER and NTG spray.
1922-09-26
Kelley882
1989-07-26
1989-07-26
13
ambulatory
185,345,009
Encounter for symptom (procedure)
85.55
3,536.75
2,829.4
195,662,009
Acute viral pharyngitis (disorder)
66
null
null
24hr Metoprolol 100mg ER tab, NTG 0.4mg/act spray
null
FIRST NAME: Kelley882 NOTE: Symptoms related to cardiac status managed with Metoprolol 100mg ER and NTG spray. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3...
656
656
Abnormal cardiac imaging noted; heart function assessment and monitoring recommended.
1922-09-26
Kelley882
1989-08-12
1989-08-12
13
ambulatory
185,347,001
Encounter for problem (procedure)
85.55
1,444.46
1,155.57
414,545,008
Ischemic heart disease (disorder)
66
null
Abn cardiac img
null
null
FIRST NAME: Kelley882 NOTE: Abnormal cardiac imaging noted; heart function assessment and monitoring recommended. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 Na...
657
657
At 71, patient managed for CKD stage 1 and diabetic nephropathy, on insulin therapy; continues full-time employment.
1922-09-26
Kelley882
1994-01-26
1994-01-26
13
wellness
162,673,000
General examination of patient (procedure)
136.8
1,361.02
1,088.8
null
null
71
null
CKD stage 1, Diabetic nephropathy, Full-time employed
70/30 insulin 100u/ml susp (Humulin)
null
FIRST NAME: Kelley882 NOTE: At 71, patient managed for CKD stage 1 and diabetic nephropathy, on insulin therapy; continues full-time employment. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
658
658
Comprehensive assessment including medication reconciliation and mental health screening performed. Insulin ongoing; stress management discussed.
1922-09-26
Kelley882
1995-01-04
1995-01-04
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
1,888.65
1,426.01
null
null
72
SerumGlucose 124.0 mg/dL, SerumBUN 7.8 mg/dL, SerumCreatinine 1.6 mg/dL, SerumCalcium 9.6 mg/dL, SerumNa 139.4 mmol/L, SerumK 3.9 mmol/L, SerumChloride 108.4 mmol/L, TotalCO2Serum 23.7 mmol/L, MDRDGFR 137.5 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Med review due, Stress
70/30 insulin 100u/ml susp (Humulin)
Med rec, Health/social needs assess, Depression screen, Depression screen, Substance use assess, Drug abuse screen, Dental referral
FIRST NAME: Kelley882 NOTE: Comprehensive assessment including medication reconciliation and mental health screening performed. Insulin ongoing; stress management discussed. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 ...
659
659
Routine dental assessment and care provided to maintain oral health.
1922-09-26
Kelley882
1995-01-18
1995-01-18
13
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,105.35
2,484.28
103,697,008
Patient referral for dental care (procedure)
72
null
null
null
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Dental bitewing, Gingival exam, Oral health ed
FIRST NAME: Kelley882 NOTE: Routine dental assessment and care provided to maintain oral health. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
660
660
Anxiety assessment conducted; medications reviewed with ongoing insulin therapy.
1922-09-26
Kelley882
1995-02-01
1995-02-01
13
wellness
162,673,000
General examination of patient (procedure)
136.8
1,402.54
1,122.02
null
null
72
SerumGlucose 118.5 mg/dL, SerumBUN 18.9 mg/dL, SerumCreatinine 1.4 mg/dL, SerumCalcium 9.1 mg/dL, SerumNa 142.8 mmol/L, SerumK 4.4 mmol/L, SerumChloride 104.9 mmol/L, TotalCO2Serum 27.9 mmol/L, MDRDGFR 137.7 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {...
Med review due
70/30 insulin 100u/ml susp (Humulin)
Med rec, Health/social needs assess, Anxiety assess
FIRST NAME: Kelley882 NOTE: Anxiety assessment conducted; medications reviewed with ongoing insulin therapy. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
661
661
Multiple screenings completed including fall risk, depression, substance use; continued insulin therapy.
1922-09-26
Kelley882
1995-05-03
1995-05-03
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
951.27
761
null
null
72
SerumGlucose 100.7 mg/dL, SerumBUN 18.2 mg/dL, SerumCreatinine 1.7 mg/dL, SerumCalcium 8.7 mg/dL, SerumNa 141.5 mmol/L, SerumK 4.5 mmol/L, SerumChloride 107.6 mmol/L, TotalCO2Serum 27.7 mmol/L, MDRDGFR 122.1 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {...
Med review due
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, AUDIT-C assess
FIRST NAME: Kelley882 NOTE: Multiple screenings completed including fall risk, depression, substance use; continued insulin therapy. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
662
662
Patient shows progression to CKD stage 2 with diabetic microalbuminuria; social isolation and part-time employment noted.
1922-09-26
Kelley882
1995-08-02
1995-08-02
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
815.27
652.2
null
null
72
SerumGlucose 102.7 mg/dL, SerumBUN 17.8 mg/dL, SerumCreatinine 2.0 mg/dL, SerumCalcium 9.1 mg/dL, SerumNa 143.0 mmol/L, SerumK 4.2 mmol/L, SerumChloride 102.2 mmol/L, TotalCO2Serum 26.4 mmol/L, MDRDGFR 74.2 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
CKD stage 2, Diabetic microalbumin, Part-time employed, Social isolation
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Kelley882 NOTE: Patient shows progression to CKD stage 2 with diabetic microalbuminuria; social isolation and part-time employment noted. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
663
663
Comprehensive exam for mental health and social issues; working full-time with ongoing stress.
1922-09-26
Kelley882
1996-02-07
1996-02-07
13
wellness
162,673,000
General examination of patient (procedure)
136.8
1,090.84
787.77
null
null
73
SerumGlucose 124.8 mg/dL, SerumBUN 13.3 mg/dL, SerumCreatinine 2.1 mg/dL, SerumCalcium 10.2 mg/dL, SerumNa 142.5 mmol/L, SerumK 4.5 mmol/L, SerumChloride 102.2 mmol/L, TotalCO2Serum 23.5 mmol/L, MDRDGFR 64.1 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {...
Full-time employed, Stress
70/30 insulin 100u/ml susp (Humulin)
Med rec, Health/social needs assess, Anxiety assess, Morse fall assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, AUDIT-C assess, Dental referral
FIRST NAME: Kelley882 NOTE: Comprehensive exam for mental health and social issues; working full-time with ongoing stress. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
664
664
Dental care including fluoride treatment and oral health education provided.
1922-09-26
Kelley882
1996-02-21
1996-02-21
13
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,105.35
2,484.28
103,697,008
Patient referral for dental care (procedure)
73
null
null
NaF 2.72% oral gel
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Gingival exam, Dental fluoride, Oral health ed
FIRST NAME: Kelley882 NOTE: Dental care including fluoride treatment and oral health education provided. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
665
665
ER visit with mental health and substance use assessment; unhealthy alcohol use identified; insulin dosing continued.
1922-09-26
Kelley882
1996-06-19
1996-06-19
13
emergency
50,849,002
Emergency room admission (procedure)
146.18
1,011.9
809.5
null
null
73
SerumGlucose 105.8 mg/dL, SerumBUN 17.0 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 10.1 mg/dL, SerumNa 143.2 mmol/L, SerumK 3.9 mmol/L, SerumChloride 110.8 mmol/L, TotalCO2Serum 20.8 mmol/L, MDRDGFR 74.8 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {...
Med review due, Unhealthy alcohol use
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Anxiety assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, AUDIT-C assess
FIRST NAME: Kelley882 NOTE: ER visit with mental health and substance use assessment; unhealthy alcohol use identified; insulin dosing continued. ENCOUNTER TYPE: emergency REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
666
666
"Medication reconciliation done during ER admission; continued insulin therapy."
1922-09-26
Kelley882
1996-06-26
1996-06-26
13
emergency
50,849,002
Emergency room admission (procedure)
146.18
1,158.14
926.5
null
null
73
SerumGlucose 100.9 mg/dL, SerumBUN 8.2 mg/dL, SerumCreatinine 2.1 mg/dL, SerumCalcium 8.9 mg/dL, SerumNa 140.3 mmol/L, SerumK 4.1 mmol/L, SerumChloride 105.8 mmol/L, TotalCO2Serum 28.0 mmol/L, MDRDGFR 74.3 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {no...
null
70/30 insulin 100u/ml susp (Humulin)
Med rec
FIRST NAME: Kelley882 NOTE: "Medication reconciliation done during ER admission; continued insulin therapy." ENCOUNTER TYPE: emergency REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
667
667
Urgent care visit including comprehensive screenings; patient under stress; insulin managed.
1922-09-26
Kelley882
1996-07-03
1996-07-03
13
urgentcare
702,927,004
Urgent care clinic (environment)
142.58
1,269.82
1,015.84
null
null
73
SerumGlucose 112.8 mg/dL, SerumBUN 14.5 mg/dL, SerumCreatinine 2.0 mg/dL, SerumCalcium 8.5 mg/dL, SerumNa 141.3 mmol/L, SerumK 4.5 mmol/L, SerumChloride 110.3 mmol/L, TotalCO2Serum 23.3 mmol/L, MDRDGFR 82.9 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Med review due, Stress
70/30 insulin 100u/ml susp (Humulin)
Med rec, Health/social needs assess, Anxiety assess, Depression screen, Depression screen, Substance use assess, AUDIT-C assess
FIRST NAME: Kelley882 NOTE: Urgent care visit including comprehensive screenings; patient under stress; insulin managed. ENCOUNTER TYPE: urgentcare REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
668
668
Follow-up in urgent care with insulin medication review due.
1922-09-26
Kelley882
1996-07-10
1996-07-10
13
urgentcare
702,927,004
Urgent care clinic (environment)
142.58
291.74
233.38
null
null
73
SerumGlucose 107.2 mg/dL, SerumBUN 9.0 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 9.4 mg/dL, SerumNa 141.8 mmol/L, SerumK 5.1 mmol/L, SerumChloride 104.3 mmol/L, TotalCO2Serum 21.2 mmol/L, MDRDGFR 61.5 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {no...
Med review due
70/30 insulin 100u/ml susp (Humulin)
null
FIRST NAME: Kelley882 NOTE: Follow-up in urgent care with insulin medication review due. ENCOUNTER TYPE: urgentcare REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
669
669
Patient presented with symptoms of viral sinusitis; symptomatic treatment recommended.
1922-09-26
Kelley882
1996-07-17
1996-07-17
13
ambulatory
185,345,009
Encounter for symptom (procedure)
85.55
85.55
68.44
444,814,009
Viral sinusitis (disorder)
73
null
Viral sinusitis
null
null
FIRST NAME: Kelley882 NOTE: Patient presented with symptoms of viral sinusitis; symptomatic treatment recommended. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 N...
670
670
Mental health and social screenings performed; gingivitis noted; patient not currently working.
1922-09-26
Kelley882
1996-07-24
1996-07-24
13
urgentcare
702,927,004
Urgent care clinic (environment)
142.58
872.3
697.82
null
null
73
SerumGlucose 100.8 mg/dL, SerumBUN 9.6 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 9.0 mg/dL, SerumNa 142.7 mmol/L, SerumK 4.0 mmol/L, SerumChloride 108.8 mmol/L, TotalCO2Serum 24.9 mmol/L, MDRDGFR 83.2 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {no...
Not in workforce, Gingivitis
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Anxiety assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, AUDIT-C assess, Dental referral
FIRST NAME: Kelley882 NOTE: Mental health and social screenings performed; gingivitis noted; patient not currently working. ENCOUNTER TYPE: urgentcare REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
671
671
Continued insulin treatment documented during urgent care visit.
1922-09-26
Kelley882
1996-07-31
1996-07-31
13
urgentcare
702,927,004
Urgent care clinic (environment)
142.58
291.74
233.38
null
null
73
SerumGlucose 116.8 mg/dL, SerumBUN 13.9 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 9.3 mg/dL, SerumNa 141.6 mmol/L, SerumK 4.5 mmol/L, SerumChloride 101.3 mmol/L, TotalCO2Serum 22.6 mmol/L, MDRDGFR 61.4 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
null
70/30 insulin 100u/ml susp (Humulin)
null
FIRST NAME: Kelley882 NOTE: Continued insulin treatment documented during urgent care visit. ENCOUNTER TYPE: urgentcare REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
672
672
Routine dental care performed including fluoride treatment.
1922-09-26
Kelley882
1996-08-07
1996-08-07
13
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,105.35
2,484.28
66,383,009
Gingivitis (disorder)
73
null
null
NaF 2.72% oral gel
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Gingival exam, Dental fluoride, Oral health ed
FIRST NAME: Kelley882 NOTE: Routine dental care performed including fluoride treatment. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
673
673
General exam includes screening for anxiety, depression, substance use and domestic abuse; gingivitis noted; patient employed part-time.
1922-09-26
Kelley882
1997-02-12
1997-02-12
13
wellness
162,673,000
General examination of patient (procedure)
136.8
1,356.33
1,059.16
null
null
74
SerumGlucose 105.7 mg/dL, SerumBUN 12.5 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 9.0 mg/dL, SerumNa 138.2 mmol/L, SerumK 4.1 mmol/L, SerumChloride 101.8 mmol/L, TotalCO2Serum 26.8 mmol/L, MDRDGFR 78.4 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Part-time employed, IPV, Gingivitis
70/30 insulin 100u/ml susp (Humulin)
Med rec, Health/social needs assess, Anxiety assess, Morse fall assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, AUDIT-C assess, Dental referral
FIRST NAME: Kelley882 NOTE: General exam includes screening for anxiety, depression, substance use and domestic abuse; gingivitis noted; patient employed part-time. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
674
674
Dental evaluation and care provided as part of routine check-up.
1922-09-26
Kelley882
1997-02-26
1997-02-26
13
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
2,673.95
2,139.16
66,383,009
Gingivitis (disorder)
74
null
null
null
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Gingival exam, Oral health ed
FIRST NAME: Kelley882 NOTE: Dental evaluation and care provided as part of routine check-up. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
675
675
Patient admitted to hospice care at age 75 for palliative management and end-of-life care planning.
1922-09-26
Kelley882
1997-10-01
1997-10-10
13
hospice
305,336,008
Admission to hospice (procedure)
137.53
6,177.13
4,755.3
126,906,006
Neoplasm of prostate (disorder)
75
null
null
null
Certification, Notifications, Initial assess, Indiv care plan, Hospice, Hospice, Hospice, Hospice, Hospice, Hospice, Hospice, Hospice, Hospice, Pt d/c
FIRST NAME: Kelley882 NOTE: Patient admitted to hospice care at age 75 for palliative management and end-of-life care planning. ENCOUNTER TYPE: hospice REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
676
676
Follow-up exam focused on social needs and fall risk; patient remains employed full-time despite limited social contact.
1922-09-26
Kelley882
1998-02-18
1998-02-18
13
wellness
162,673,000
General examination of patient (procedure)
136.8
1,002.52
802
null
null
75
SerumGlucose 122.2 mg/dL, SerumBUN 8.8 mg/dL, SerumCreatinine 2.1 mg/dL, SerumCalcium 10.1 mg/dL, SerumNa 142.3 mmol/L, SerumK 5.1 mmol/L, SerumChloride 109.4 mmol/L, TotalCO2Serum 25.5 mmol/L, MDRDGFR 63.2 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Med review due, Full-time employed, Limited social contact
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Morse fall assess
FIRST NAME: Kelley882 NOTE: Follow-up exam focused on social needs and fall risk; patient remains employed full-time despite limited social contact. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
677
677
Assessment includes mental health screening and dental referral; patient experiencing social isolation and stress; gingivitis present.
1922-09-26
Kelley882
1999-02-10
1999-02-10
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
951.27
735.86
null
null
76
SerumGlucose 107.8 mg/dL, SerumBUN 19.9 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 9.1 mg/dL, SerumNa 140.5 mmol/L, SerumK 4.0 mmol/L, SerumChloride 107.7 mmol/L, TotalCO2Serum 28.3 mmol/L, MDRDGFR 76.6 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Part-time employed, Social isolation, Stress, Gingivitis
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Depression screen, Depression screen, Dental referral
FIRST NAME: Kelley882 NOTE: Assessment includes mental health screening and dental referral; patient experiencing social isolation and stress; gingivitis present. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
678
678
Comprehensive exam and screenings; patient currently not working.
1922-09-26
Kelley882
1999-02-24
1999-02-24
13
wellness
162,673,000
General examination of patient (procedure)
136.8
1,729.32
1,383.44
null
null
76
SerumGlucose 117.6 mg/dL, SerumBUN 10.1 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 9.1 mg/dL, SerumNa 138.4 mmol/L, SerumK 4.7 mmol/L, SerumChloride 105.8 mmol/L, TotalCO2Serum 28.7 mmol/L, MDRDGFR 68.3 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Not in workforce
70/30 insulin 100u/ml susp (Humulin)
Med rec, Health/social needs assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Kelley882 NOTE: Comprehensive exam and screenings; patient currently not working. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
679
679
Dental care including fluoride treatment performed.
1922-09-26
Kelley882
1999-03-03
1999-03-03
13
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,536.75
2,829.4
66,383,009
Gingivitis (disorder)
76
null
null
NaF 2.72% oral gel
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Dental bitewing, Gingival exam, Dental fluoride, Oral health ed
FIRST NAME: Kelley882 NOTE: Dental care including fluoride treatment performed. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
680
680
Screenings conducted for mental health and substance use; patient stressed but fully employed.
1922-09-26
Kelley882
1999-04-14
1999-04-14
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
951.27
761
null
null
76
SerumGlucose 117.9 mg/dL, SerumBUN 9.3 mg/dL, SerumCreatinine 2.0 mg/dL, SerumCalcium 10.1 mg/dL, SerumNa 143.0 mmol/L, SerumK 4.2 mmol/L, SerumChloride 103.5 mmol/L, TotalCO2Serum 25.5 mmol/L, MDRDGFR 73.5 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Med review due, Full-time employed, Stress
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Anxiety assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Kelley882 NOTE: Screenings conducted for mental health and substance use; patient stressed but fully employed. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
681
681
Patient progressed to CKD stage 3 with proteinuria; gingivitis noted; dental referral given.
1922-09-26
Kelley882
1999-05-12
1999-05-12
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
1,147.11
917.67
null
null
76
SerumGlucose 100.5 mg/dL, SerumBUN 17.5 mg/dL, SerumCreatinine 2.1 mg/dL, SerumCalcium 9.4 mg/dL, SerumNa 137.4 mmol/L, SerumK 4.3 mmol/L, SerumChloride 108.2 mmol/L, TotalCO2Serum 28.5 mmol/L, MDRDGFR 47.0 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
CKD stage 3, Diabetic proteinuria, Gingivitis
70/30 insulin 100u/ml susp (Humulin)
Med rec, Health/social needs assess, Morse fall assess, Dental referral
FIRST NAME: Kelley882 NOTE: Patient progressed to CKD stage 3 with proteinuria; gingivitis noted; dental referral given. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 ...
682
682
Advanced dental treatments performed addressing gum disease and leaking filling.
1922-09-26
Kelley882
1999-05-26
1999-05-26
13
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
5,262.35
4,209.88
66,383,009
Gingivitis (disorder)
76
null
Gum disease, Leaking filling
NaF 2.72% oral gel
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Gingival exam, Dental surgery, Dental desensitizing, Gingivectomy, Dental postop care, Full cusp coverage, Dental fluoride, Oral health ed
FIRST NAME: Kelley882 NOTE: Advanced dental treatments performed addressing gum disease and leaking filling. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
683
683
Assessments for social and substance use completed; medication review noted.
1922-09-26
Kelley882
1999-08-11
1999-08-11
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
815.27
652.2
null
null
76
SerumGlucose 121.9 mg/dL, SerumBUN 16.9 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 9.5 mg/dL, SerumNa 139.1 mmol/L, SerumK 4.0 mmol/L, SerumChloride 105.6 mmol/L, TotalCO2Serum 25.9 mmol/L, MDRDGFR 51.1 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Med review due
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Substance use assess, Drug abuse screen, Dental referral
FIRST NAME: Kelley882 NOTE: Assessments for social and substance use completed; medication review noted. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
684
684
Standard dental care performed during routine checkup.
1922-09-26
Kelley882
1999-08-25
1999-08-25
13
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,105.35
2,484.28
103,697,008
Patient referral for dental care (procedure)
76
null
null
null
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Dental bitewing, Gingival exam, Oral health ed
FIRST NAME: Kelley882 NOTE: Standard dental care performed during routine checkup. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
685
685
Routine health and psychosocial assessments; insulin therapy ongoing.
1922-09-26
Kelley882
1999-10-13
1999-10-13
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
815.27
652.2
null
null
77
SerumGlucose 108.6 mg/dL, SerumBUN 17.0 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 9.2 mg/dL, SerumNa 138.7 mmol/L, SerumK 4.1 mmol/L, SerumChloride 109.0 mmol/L, TotalCO2Serum 27.3 mmol/L, MDRDGFR 32.0 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
null
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Kelley882 NOTE: Routine health and psychosocial assessments; insulin therapy ongoing. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
686
686
Follow-up screening for depression and substance use conducted.
1922-09-26
Kelley882
1999-11-10
1999-11-10
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
815.27
652.2
null
null
77
SerumGlucose 115.7 mg/dL, SerumBUN 18.5 mg/dL, SerumCreatinine 2.0 mg/dL, SerumCalcium 8.5 mg/dL, SerumNa 144.0 mmol/L, SerumK 3.7 mmol/L, SerumChloride 104.7 mmol/L, TotalCO2Serum 23.9 mmol/L, MDRDGFR 56.5 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
null
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Kelley882 NOTE: Follow-up screening for depression and substance use conducted. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
687
687
Urgent care visit with comprehensive assessments; patient noted unemployed.
1922-09-26
Kelley882
1999-12-08
1999-12-08
13
urgentcare
702,927,004
Urgent care clinic (environment)
142.58
1,735.1
1,388.06
null
null
77
SerumGlucose 122.5 mg/dL, SerumBUN 18.9 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 9.2 mg/dL, SerumNa 142.2 mmol/L, SerumK 4.6 mmol/L, SerumChloride 109.9 mmol/L, TotalCO2Serum 21.4 mmol/L, MDRDGFR 51.0 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Unemployed
70/30 insulin 100u/ml susp (Humulin)
Med rec, Health/social needs assess, Morse fall assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Kelley882 NOTE: Urgent care visit with comprehensive assessments; patient noted unemployed. ENCOUNTER TYPE: urgentcare REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
688
688
Mental health and substance use screenings; social isolation addressed.
1922-09-26
Kelley882
2000-01-05
2000-01-05
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
889.85
711.86
null
null
77
SerumGlucose 105.0 mg/dL, SerumBUN 9.5 mg/dL, SerumCreatinine 2.1 mg/dL, SerumCalcium 8.6 mg/dL, SerumNa 142.7 mmol/L, SerumK 4.9 mmol/L, SerumChloride 109.2 mmol/L, TotalCO2Serum 20.4 mmol/L, MDRDGFR 35.5 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {no...
Med review due, Social isolation
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Anxiety assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, AUDIT-C assess
FIRST NAME: Kelley882 NOTE: Mental health and substance use screenings; social isolation addressed. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
689
689
Comprehensive screening including domestic abuse and substance use.
1922-09-26
Kelley882
2000-02-09
2000-02-09
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
815.27
652.2
null
null
77
SerumGlucose 116.3 mg/dL, SerumBUN 18.4 mg/dL, SerumCreatinine 2.1 mg/dL, SerumCalcium 8.5 mg/dL, SerumNa 139.3 mmol/L, SerumK 5.0 mmol/L, SerumChloride 109.6 mmol/L, TotalCO2Serum 24.3 mmol/L, MDRDGFR 36.8 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
null
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Morse fall assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, AUDIT-C assess
FIRST NAME: Kelley882 NOTE: Comprehensive screening including domestic abuse and substance use. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
690
690
Extensive mental health and social screening; social isolation reported.
1922-09-26
Kelley882
2000-03-01
2000-03-01
13
wellness
162,673,000
General examination of patient (procedure)
136.8
1,082.22
865.76
null
null
77
SerumGlucose 111.0 mg/dL, SerumBUN 19.1 mg/dL, SerumCreatinine 2.0 mg/dL, SerumCalcium 9.0 mg/dL, SerumNa 141.4 mmol/L, SerumK 5.0 mmol/L, SerumChloride 104.1 mmol/L, TotalCO2Serum 20.5 mmol/L, MDRDGFR 54.5 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Social isolation
70/30 insulin 100u/ml susp (Humulin)
Med rec, Health/social needs assess, Anxiety assess, Morse fall assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Kelley882 NOTE: Extensive mental health and social screening; social isolation reported. ENCOUNTER TYPE: wellness REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
691
691
Medication review performed during check-up; insulin therapy continued.
1922-09-26
Kelley882
2000-03-08
2000-03-08
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
234.71
187.76
null
null
77
SerumGlucose 100.9 mg/dL, SerumBUN 14.8 mg/dL, SerumCreatinine 2.0 mg/dL, SerumCalcium 9.8 mg/dL, SerumNa 136.2 mmol/L, SerumK 4.2 mmol/L, SerumChloride 105.2 mmol/L, TotalCO2Serum 27.2 mmol/L, MDRDGFR 44.5 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Med review due
70/30 insulin 100u/ml susp (Humulin)
null
FIRST NAME: Kelley882 NOTE: Medication review performed during check-up; insulin therapy continued. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
692
692
Urgent care visit with mental health and dental referral due to gingivitis.
1922-09-26
Kelley882
2000-05-10
2000-05-10
13
urgentcare
702,927,004
Urgent care clinic (environment)
142.58
1,008.3
806.62
null
null
77
SerumGlucose 121.9 mg/dL, SerumBUN 11.9 mg/dL, SerumCreatinine 2.0 mg/dL, SerumCalcium 9.7 mg/dL, SerumNa 141.2 mmol/L, SerumK 4.8 mmol/L, SerumChloride 102.3 mmol/L, TotalCO2Serum 24.0 mmol/L, MDRDGFR 40.3 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Gingivitis
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Morse fall assess, Depression screen, Depression screen, Dental referral
FIRST NAME: Kelley882 NOTE: Urgent care visit with mental health and dental referral due to gingivitis. ENCOUNTER TYPE: urgentcare REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
693
693
Routine insulin management seen during check-up.
1922-09-26
Kelley882
2000-05-17
2000-05-17
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
234.71
187.76
null
null
77
SerumGlucose 100.7 mg/dL, SerumBUN 16.8 mg/dL, SerumCreatinine 2.0 mg/dL, SerumCalcium 10.1 mg/dL, SerumNa 143.4 mmol/L, SerumK 4.0 mmol/L, SerumChloride 105.3 mmol/L, TotalCO2Serum 23.3 mmol/L, MDRDGFR 35.3 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {...
null
70/30 insulin 100u/ml susp (Humulin)
null
FIRST NAME: Kelley882 NOTE: Routine insulin management seen during check-up. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
694
694
Comprehensive dental care provided for gum disease.
1922-09-26
Kelley882
2000-05-24
2000-05-24
13
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
4,830.95
3,864.76
66,383,009
Gingivitis (disorder)
77
null
Gum disease
null
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Dental bitewing, Gingival exam, Dental surgery, Dental desensitizing, Gingivectomy, Dental postop care, Oral health ed
FIRST NAME: Kelley882 NOTE: Comprehensive dental care provided for gum disease. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
695
695
Routine mental health and substance use screening; patient working full-time.
1922-09-26
Kelley882
2000-06-07
2000-06-07
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
815.27
652.2
null
null
77
SerumGlucose 109.7 mg/dL, SerumBUN 7.9 mg/dL, SerumCreatinine 2.0 mg/dL, SerumCalcium 9.8 mg/dL, SerumNa 138.3 mmol/L, SerumK 5.1 mmol/L, SerumChloride 101.1 mmol/L, TotalCO2Serum 23.8 mmol/L, MDRDGFR 37.2 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {no...
Full-time employed
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Anxiety assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, AUDIT-C assess, Dental referral
FIRST NAME: Kelley882 NOTE: Routine mental health and substance use screening; patient working full-time. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
696
696
Dental fluoride treatment and oral health education delivered.
1922-09-26
Kelley882
2000-06-21
2000-06-21
13
ambulatory
185,349,003
Encounter for check up (procedure)
85.55
3,105.35
2,484.28
103,697,008
Patient referral for dental care (procedure)
77
null
null
NaF 2.72% oral gel
Dental consult, Dental care, Supragingival scaling, Subgingival scaling, Gingival exam, Dental fluoride, Oral health ed
FIRST NAME: Kelley882 NOTE: Dental fluoride treatment and oral health education delivered. ENCOUNTER TYPE: ambulatory REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
697
697
Screenings completed; patient part-time employed.
1922-09-26
Kelley882
2000-07-05
2000-07-05
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
815.27
652.2
null
null
77
SerumGlucose 108.2 mg/dL, SerumBUN 18.2 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 8.5 mg/dL, SerumNa 139.1 mmol/L, SerumK 3.9 mmol/L, SerumChloride 109.5 mmol/L, TotalCO2Serum 21.7 mmol/L, MDRDGFR 56.8 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Part-time employed
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Morse fall assess, Depression screen, Depression screen
FIRST NAME: Kelley882 NOTE: Screenings completed; patient part-time employed. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
698
698
Urgent care address social and mental health needs.
1922-09-26
Kelley882
2000-08-02
2000-08-02
13
urgentcare
702,927,004
Urgent care clinic (environment)
142.58
872.3
697.82
null
null
77
SerumGlucose 102.1 mg/dL, SerumBUN 10.1 mg/dL, SerumCreatinine 1.9 mg/dL, SerumCalcium 8.7 mg/dL, SerumNa 136.5 mmol/L, SerumK 4.1 mmol/L, SerumChloride 109.8 mmol/L, TotalCO2Serum 24.3 mmol/L, MDRDGFR 38.6 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
null
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Domestic abuse screen, Depression screen, Depression screen, Substance use assess, Drug abuse screen
FIRST NAME: Kelley882 NOTE: Urgent care address social and mental health needs. ENCOUNTER TYPE: urgentcare REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...
699
699
Patient under stress; fully employed; routine assessments conducted.
1922-09-26
Kelley882
2000-08-30
2000-08-30
13
outpatient
185,349,003
Encounter for check up (procedure)
85.55
815.27
652.2
null
null
77
SerumGlucose 112.8 mg/dL, SerumBUN 17.6 mg/dL, SerumCreatinine 2.1 mg/dL, SerumCalcium 8.5 mg/dL, SerumNa 142.0 mmol/L, SerumK 4.0 mmol/L, SerumChloride 102.3 mmol/L, TotalCO2Serum 27.4 mmol/L, MDRDGFR 55.1 mL/min/{1.73_m2}, UrineAppearance Cloudy urine (finding) {nominal}, UrineOdor Urine smell ammoniacal (finding) {n...
Full-time employed, Stress
70/30 insulin 100u/ml susp (Humulin)
Health/social needs assess, Anxiety assess, Morse fall assess, Depression screen, Depression screen, Substance use assess, AUDIT-C assess
FIRST NAME: Kelley882 NOTE: Patient under stress; fully employed; routine assessments conducted. ENCOUNTER TYPE: outpatient REASON FOR ENCOUNTER: 0 NaN 1 NaN 2 NaN 3 ...