Neighborhood Physicians PracticeBeaverton, OR

MCKINEY, Karen Jones;
MCKINEY, Cathy Jones

May 1, 1970
Date of Birth
Female
Sex
083178
Patient Id
1357 Amber Dr
Beaverton, OR 97006
Address
(555)777-1234
Mobile Phone
(555)723-1544
Home Phone
en (preferred)
Language
White
European
Race
Not Hispanic or Latino
Ethnicity
Married
Marital Status

170.315 b9 Care Plan Ambulatory Sample 1 (v9)

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Care Plan Summary

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
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Health Concerns

Health Status
Chronic sickness 6/22/2015
Concerns
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
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Goals

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
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Interventions

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
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Health Status Evaluations and Outcomes

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
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Health Care Providers

Internal Medicine (primary care physician)
Dr Albert Davis
2472 Rocky place
Beaverton, OR 97006
Address
(555)555-1002
Work Phone
Tracy Davis
2472 Rocky place
Beaverton, OR 97006
Address
(555)555-1002
Work Phone
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Patient Contacts

Next of Kin (spouse)
Matthew McKiney
1357 Amber Dr
Beaverton, OR 97006
Address
(555)723-1544
Home Phone
Next of Kin (grandfather)
Rick Grazino
1357 Amber Dr
Beaverton, OR 97006
Address
(555)723-1544
Home Phone
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Document Details

Neighborhood Physicians Practice
Dr Albert Davis
November 2, 2016 13:07 -0400
Published
2472 Rocky place
Beaverton, OR 97006
Address
(555)555-1002
Work Phone