Continuity of Care (CCD) (February 11, 2019, 10:17AM -0600)

Patient Theodore LEVEN Date of Birth: March 22, 1942 (76yr) Gender: Male Patient-ID:  M20190410142823.6 (2.16.840.1.113883.3.4988), Ted.Leven@direct.MyPHD.us (1.3.6.1.4.1.41179.2.4)
Documentation Of Care provision, Date/Time: from January 1, 2018 to February 11, 2019, 10:17AM, Performer: John Smith, MD
Author John Smith, MD, Organization: John Smith, MD, LLC, Authored On: February 11, 2019, 10:17AM -0600
Author MaxMD C-CDA Creator, Authored On: February 11, 2019, 10:17AM -0600
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Encounter Section

Encounters during this range of time:
Date: April 15, 2018 Encounter Type: Office Visit Provider: Elinor Endo, MD Practice: Endocrinology Group of Chicago
Date: March 05, 2018 Encounter Type: Office Visit Provider: John Smith, MD Practice: John Smith, MD LLC

Problem History Section (entries optional)

Type 2 Diabetes Mellitus, Active, diagnosed in 2006
Osteoarthritis diagnosed in 2010
Peripheral Artery Disease diagnosed in 2013
Amputated Left Foot 2013

Allergies and Intolerances History Section

No known Allergies

Medication History Section

Atorvastatin 20mg PO daily for peripheral artery disease
Lantus 14 units subcutaneous injection daily for diabetes
Lisinopril 10mg PO daily for peripheral artery disease and diabetes
Aspirin 81mg PO daily for peripheral artery disease
Tylenol 650mg PO Q8hr as needed for arthritis pain

Immunizations History Section (entries optional)

Influenza vaccine administered 10/2017 Tdap vaccine administered 2009

Test Results History Section (entries required)

3/5/2018
Hemoglobin A1c 7.2
9/20/2017
Hemoglobin A1c 7.0
3/10/2018
Cholesterol 196
triglycerides 114
HDL 40
LDL 136
Spot microalbumin 9.2 micrograms of protein

Social History Section

Widowed in 2017, Lives alone, but son lives in same area. Goes to senior center during the day to keep busy.
Smoking history: previous history of smoking ½ pack per day. Started smoking in 1960 quit in 2010
Smoking Status
  • Former Smoker Started: 1960 Stopped: 2010 Recorded April 15, 2018 9:00am
Alcohol Use: 1-2 beers per week
Drug Use: No history of drug use

Family History Section

Negative for diabetes Father died at age 79, history of heart disease
Mother died at age 85, history of stroke

Procedures History Section

Left foot amputation 2013

Medical Equipment Section

Crutches Wheelchair Prosthetic Left Leg

Vital Signs Section

9/25/2017 Weight: 170 lbs
Height: 5ft10inches
Blood Pressure:125/65
BMI: 24
4/15/2018 Weight: 181 lbs
Height: 5ft10inches
Blood Pressure:125/70
BMI: 26
Document
ID 6543c3e1-58d3-4882-a9c7-8cf9d67c8d90 (ec23388d-5686-49d7-b36b-06bd670d7cd6)
Version 1
Created On February 11, 2019, 10:17AM -0600
Custodian John Smith, MD, LLC Contact Details 40 Healthcare Ave.
Suite 100
Chicago, IL 60643
US
Tel Workplace: 312 555 5555
 
Patient Theodore LEVEN Contact Details 123 State Street
Chicago, IL 60601
US
Tel Home Primary: 312 999 4321, Tel Mobile: 312 123 1234, Mail: TedLeven400@gmail.com, Mail Home Primary: Ted.Leven@direct.MyPHD.us
Date of Birth March 22, 1942 (76yr) Gender Male
Patient-IDs M20190410142823.6 (2.16.840.1.113883.3.4988)
Ted.Leven@direct.MyPHD.us (1.3.6.1.4.1.41179.2.4)
 
Documentation Of - care provision from January 1, 2018 to February 11, 2019, 10:17AM
Performer - Primary Care Provider - Primary Care Provider John Smith, MD Contact Details 40 Healthcare Ave.
Suite 100
Chicago, IL 60643
US
Tel Workplace: 312 555 5555
 
Author John Smith, MD, Organization: John Smith, MD, LLC Contact Details 40 Healthcare Ave.
Suite 100
Chicago, IL 60643
US
Tel Workplace: 312 222 4321, Mail Home Primary: JohnSmithMD@gmail.com
Contact Details (Organization) 40 Healthcare Ave.
Suite 100
Chicago, IL 60643
US
Author MaxMD C-CDA Creator Contact Details 2200 Fletcher Ave.
Suite 506
Fort Lee, NJ 07024
US
Tel Workplace: 201 963 0005, Mail Home Primary: syntheticDataMaker@max.md