| Patient is overweight as shown by the vital sign height and weight observations (6/22/2015 at 10:05 EST) (Active) Start: 6/22/2015 |
| • Goal: Keep weight under 95kg |
| ◦ Intervention: Nutrition: dietary regime (regime/therapy); nutrition education (procedure) |
| ◦ Outcome: a. Outcome Observation #1:i. Refers to Goal Observation for Weight; ii. Refers to the Intervention Act #1; iii. Progress Towards Goal of Weight – Goal Not Achieved as of 6/22/2015 |
| Fever (6/22/2015 at 10:10 EST) (Active) Start: 6/22/2015 |
| • Goal: Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit |
| ◦ Milestone: Get rid of intermittent fever that is occurring every few weeks. |
| ◦ Intervention: Medications: Tylenol 500 mg |
| ▪ Outcome: b. Outcome Observation #2: i. Refers to Goal Observation for Body Temperature; ii. Refers to Intervention Act #2 iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015 |
| ◦ Outcome: b. Outcome Observation #2: i. Refers to Goal Observation for Body Temperature; ii. Refers to Intervention Act #2 iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015 |
| Increased body temperature as evidenced by Intermittent (recurrent) fever (Active) Start: 6/22/2015 |
| • Goal: Get rid of intermittent fever that is occurring every few weeks. |
| ◦ Intervention: Medications: Ceftriaxone 100 MG/ML |
| Fatigue (Active) Start: 12/31/2006 |
| • Goal: Need to gain more energy to do regular activities. |
| ◦ Intervention: Medications: Levothyroxine Sodium 1 mg |
| Hypertension: BP 145/88 (6/22/2015 at 10:08 EST) (Active) Start: 6/22/2015 |
| Renal transplant rejection (Active) Start: 6/22/2015 |
| • Goal: Improve renal function |
| ◦ Intervention: Medications: Aranesp 0.5 MG/ML |
| Chronic sickness | 6/22/2015 |
| Patient is overweight as shown by the vital sign height and weight observations (6/22/2015 at 10:05 EST) | Start: 6/22/2015 |
Status: Active Provider Concern |
| Related To: | ||
| •Overweight | Onset: 12/31/2006 |
Status: Active |
| •Weight 110 kg | 22-Jun-2015 10:05 | |
| •Height 177 cm | 22-Jun-2015 10:05 | |
| Fever (6/22/2015 at 10:10 EST) | Start: 6/22/2015 |
Status: Active Provider Concern |
| Related Health Concern: Increased body temperature as evidenced by Intermittent (recurrent) fever | ||
| Related To: | ||
| •Temperature 103 f | 22-Jun-2015 10:10 | |
| Increased body temperature as evidenced by Intermittent (recurrent) fever | Start: 6/22/2015 |
Status: Active Provider Concern |
| Associated Health Concern: Fever (6/22/2015 at 10:10 EST) | ||
| Related To: | ||
| •Intermittent (recurrent) fever | Onset: 6/22/2015 |
Status: Active |
| •Encounter Diagnosis: Fever | Status: Active Onset: 6/22/2015 |
|
| Fatigue | Start: 12/31/2006 |
Status: Active Provider Concern |
| Related To: | ||
| •Severe Hypothyroidism | Onset: 12/31/2006 |
Status: Active |
| Hypertension: BP 145/88 (6/22/2015 at 10:08 EST) | Start: 6/22/2015 |
Status: Active Provider Concern |
| Related To: | ||
| •Hypertension | Onset: 10/5/2011 |
Status: Active |
| •BP Systolic 145 mm[Hg] | 22-Jun-2015 10:05 | |
| •BP Diastolic 88 mm[Hg] | 22-Jun-2015 10:05 | |
| Renal transplant rejection | Start: 6/22/2015 |
Status: Active Provider Concern |
| Related To: | ||
| •Chronic rejection of renal transplant | Onset: 12/31/2011 |
Status: Active |
| Get rid of intermittent fever that is occurring every few weeks. | Goal Set: 6/22/2015 | Patient and Provider Goal |
| Related To: | ||
| •Increased body temperature as evidenced by Intermittent (recurrent) fever | ||
| Interventions | ||
| •Ceftriaxone 100 MG/ML | ||
| Need to gain more energy to do regular activities. | Goal Set: 6/22/2015 | Patient and Provider Goal |
| Related To: | ||
| •Fatigue | ||
| Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit | Goal Set: 6/22/2015 | Patient and Provider Goal |
| Related To: | ||
| •Fever (6/22/2015 at 10:10 EST) | ||
| Interventions | ||
| •Tylenol 500 mg | ||
| Milestones | ||
| •Get rid of intermittent fever that is occurring every few weeks. | ||
| Keep weight under 95kg | Goal Set: 6/22/2015 | Provider Goal |
| Related To: | ||
| •Patient is overweight as shown by the vital sign height and weight observations (6/22/2015 at 10:05 EST) | ||
| Interventions | ||
| •dietary regime (regime/therapy) | ||
| •nutrition education (procedure) | ||
| Improve renal function | Goal Set: 6/22/2015 | Patient and Provider Goal |
| Related To: | ||
| •Renal transplant rejection | ||
| Interventions | ||
| •Aranesp 0.5 MG/ML | ||
| Intervention For: Keep weight under 95kg | ||
| •dietary regime (regime/therapy) | Intent | |
| •nutrition education (procedure) | Intent | |
| Intervention For: Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit | ||
| •Tylenol 500 mg; oral as needed | Start: 6/22/2015 End: 6/30/2015 |
Status: Complete |
| Intervention For: Need to gain more energy to do regular activities. | ||
| •Levothyroxine Sodium 1 mg; oral daily | Start: 6/23/2015 End: 6/30/2015 |
Status: Complete |
| Intervention For: Get rid of intermittent fever that is occurring every few weeks. | ||
| •Ceftriaxone 100 MG/ML; two times daily | Start: 6/22/2015 End: 7/22/2015 |
Status: Complete |
| Intervention For: Improve renal function | ||
| •Aranesp 0.5 MG/ML; Injectable Once a week | Start: 6/22/2015 End: 7/22/2015 |
Status: Complete |
| a. Outcome Observation #1:i. Refers to Goal Observation for Weight; ii. Refers to the Intervention Act #1; iii. Progress Towards Goal of Weight – Goal Not Achieved as of 6/22/2015 |
||
| Related Goal: | ||
| •Keep weight under 95kg | ||
| Progress: | ||
| •Goal not achieved | 6/22/2015 | |
| b. Outcome Observation #2: i. Refers to Goal Observation for Body Temperature; ii. Refers to Intervention Act #2 iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015 |
||
| Related Goal: | ||
| •Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit | ||
| Interventions: | ||
| •Tylenol 500 mg | ||
| Progress: | ||
| •Goal achieved | 6/22/2015 | |