Visualize HL7 Example and Test Instances (vi7eti), pronounced /viːˈsɛtiː/
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European Patient Summary

Patient
Name: Joubert, Patricia
DOB: 10-SEP-1939 (Age: 86)
Gender: female
ID: 7843-162355-8 (ECI)
Author
Legendre, Sabine
Patient summary Document
European Patient Summary
Report Date: 09-JUL-2025

Problem list

Condition Onset Date / Period Status
Chronic kidney disease stage 3 09-Nov-2022 active
Proteinuria due to type 2 diabetes mellitus 09-Nov-2022 active
Chronic kidney disease stage 2 05-Oct-2016 active
Microalbuminuria due to type 2 diabetes mellitus 05-Oct-2016 active
Alzheimer's disease 16-Sep-2015 active
Acute ST segment elevation myocardial infarction 11-Aug-2013 active
Disorder of kidney due to diabetes mellitus 24-Sep-2008 active
Ischemic heart disease 24-Sep-2008 active
Chronic kidney disease stage 1 24-Sep-2008 active
Chronic sinusitis 19-Dec-2007 active
Mitral valve stenosis 06-Dec-2004 active
Hyperlipidemia 14-Mar-1990 active
Metabolic syndrome X 11-Apr-1979 active
Essential hypertension 13-Mar-1974 active
Fracture of clavicle 29-Jan-2025 - 15-Apr-2025 inactive
Fracture of bone 29-Jan-2025 - 15-Apr-2025 inactive
Acute bronchitis 26-Sep-2022 - 05-Oct-2022 inactive
Viral sinusitis 24-May-2017 - 06-Jun-2017 inactive
Acute viral pharyngitis 06-Jan-2016 - 20-Jan-2016 inactive

Medication list

Medication Since Form Dosage Reason
Human isophane insulin 70 unit/mL and recombinant human regular insulin 30 unit/mL solution for injection 2025-07-09 - Inject 10 units (0.1 mL) subcutaneously before breakfast and before dinner Prediabetes
Amlodipine (as amlodipine besylate) 2.5 mg oral tablet 2025-07-09 - 1 tablet (2.5 mg) by mouth once daily Essential hypertension (disorder)
Hydrochlorothiazide 25 mg oral tablet 2025-07-09 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Lisinopril 10 mg oral tablet 2025-07-09 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
Simvastatin 10 mg oral tablet 2025-05-15 - 1 tablet (10 mg) by mouth once daily Hyperlipidemia
Galantamine (as galantamine hydrobromide) 4 mg oral tablet 2015-09-16 - 1 tablet (4 mg) once daily Alzheimer's disease (disorder)
Aspirin 81 mg gastro-resistant oral tablet 2013-08-11 - 1 tablet (81 mg) once daily -
Prasugrel (as prasugrel hydrochloride) 10 mg oral tablet 2013-08-11 - 1 tablet (10 mg) once daily -
Rosuvastatin (as rosuvastatin calcium) 40 mg oral tablet 2013-08-11 - 1 tablet (40 mg) once daily -
Labetalol hydrochloride 100 mg oral tablet 2013-08-11 - 1 tablet (100 mg) by mouth twice daily -
Hydrochlorothiazide 25 mg and losartan potassium 100 mg oral tablet 2013-08-11 - 1 tablet (25 mg hydrochlorothiazide and 100 mg losartan potassium) by mouth once daily -
Clopidogrel (as clopidogrel bisulfate) 75 mg oral tablet 2008-10-01 - 1 tablet (75 mg) once daily -
Simvastatin 20 mg oral tablet 2008-10-01 - 1 tablet (20 mg) by mouth once daily -
Nitroglycerin 400 microgram/actuation sublingual spray 2008-10-01 - 1 spray (400 micrograms) under the tongue as needed for chest pain, may repeat every 5 minutes as needed, up to 3 sprays in 15 minutes -
Metoprolol tartrate (as metoprolol succinate) 100 mg prolonged-release oral tablet 2008-10-01 - 1 tablet (100 mg) once daily -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 25-Jun-2025
SARS-CoV-2 mRNA vaccine 10-Mar-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 03-Jan-2018

Procedure History list

Procedure Date Reason
Depression screening 25-Jun-2025 -
Assessment of health and social care needs 25-Jun-2025 -
Assessment of anxiety 25-Jun-2025 -
Assessment using Morse Fall Scale 25-Jun-2025 -
Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) 25-Jun-2025 -
Assessment of substance use 25-Jun-2025 -
Screening for substance abuse 30-Apr-2025 -
Medication reconciliation 26-Feb-2025 -
Screening for domestic abuse 26-Feb-2025 -
Plain X-ray of clavicle 29-Jan-2025 -
Admission to orthopedic department 29-Jan-2025 Fracture of clavicle (disorder)
Bone density scan 29-Jan-2025 Fracture of clavicle (disorder)
Depression screening using PHQ-9 (Patient Health Questionnaire 9) score 15-Jun-2022 -
Patient discharge 03-Jan-2022 -
Hospice care 02-Jan-2022 -
Notifications 29-Dec-2021 -
Certification procedure 29-Dec-2021 -
Initial patient assessment 29-Dec-2021 -
Development of individualized plan of care 29-Dec-2021 -

Allergies and Intolerances

No known allergies or intolerances

Care Plan

Active Planned Care / Goals Start Date Reason
Dementia management 16-Sep-2015 Alzheimer's disease (disorder)
  • Support maintenance or slow decline of cognitive abilities in the context of Alzheimer's disease through dementia management interventions.
  • Promote independence in activities of daily living for as long as possible through dementia management strategies.
  • Reduce frequency and severity of behavioral and psychological symptoms associated with Alzheimer's disease.
  • Implement measures to reduce risk of harm related to cognitive impairment, such as fall prevention and medication safety.
Discharge care plan 11-Aug-2013 -
Hyperlipidemia clinical management plan 04-Apr-1990 Hyperlipidemia (disorder)
  • Achieve LDL cholesterol below 70 mg/dL to reduce cardiovascular risk.
  • Maintain total cholesterol below 200 mg/dL.
  • Maintain HDL cholesterol above 50 mg/dL.
  • Maintain triglycerides below 150 mg/dL.
Lifestyle education regarding hypertension 13-Mar-1974 Essential hypertension (disorder)
  • Patient will implement recommended lifestyle modifications to help control blood pressure, including dietary changes, increased physical activity, and medication adherence.
Diabetes self management plan 28-Feb-1962 Prediabetes (finding)
  • Maintain HbA1c at or below individualized target to reduce risk of diabetes complications.
  • Maintain blood pressure below 130/80 mmHg to reduce cardiovascular and renal risk.
  • Achieve and maintain a healthy body weight through diet and physical activity as part of diabetes self-management.
  • Engage in regular physical activity as tolerated to support glycemic control and overall health.
  • Follow a balanced diet with appropriate carbohydrate intake to support glycemic control and kidney health.
Immunization Recommendation Due Date Reason
Influenza virus antigen only vaccine product 01-Oct-2026 Annual seasonal influenza vaccination

Vital Signs

Vital Signs 2025-07-09 2025-06-25
Body Height 162 cm 162 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 0 {score} 1 {score}
Body Weight 73.7 kg 73.7 kg
Body mass index (BMI) [Ratio] 28.1 kg/m2 28.1 kg/m2
Heart rate 64 /min 83 /min
Respiratory rate 13 /min 15 /min
Blood pressure panel with all children optional 66 mm[Hg] 56 mm[Hg]

Relevant diagnostic tests/laboratory data

Recent Lab Observations 09-JUL-2025 Reference Range Unit
Glucose [Mass/volume] in Serum or Plasma 95.2 70 - 140 mg/dL
Urea nitrogen [Mass/volume] in Serum or Plasma 18.4 7 - 20 mg/dL
Creatinine [Mass/volume] in Serum or Plasma 1.9 H 0.6 - 1.3 mg/dL
Calcium [Mass/volume] in Serum or Plasma 9.5 8.6 - 10.3 mg/dL
Sodium [Moles/volume] in Serum or Plasma 137.7 135 - 145 mmol/L
Potassium [Moles/volume] in Serum or Plasma 5.1 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Serum or Plasma 106.9 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Serum or Plasma 21.6 L 22 - 29 mmol/L
Appearance of Urine Cloudy urine
Odor of Urine Urine smell ammoniacal
Clarity of Urine Translucent
Color of Urine Brown color
Glucose [Mass/volume] in Urine by Test strip 1.8 0 - 5 mg/dL
Glucose [Presence] in Urine by Test strip Urine glucose test = ++
Bilirubin.total [Mass/volume] in Urine by Test strip 1.1 0 - 4 mg/dL
Bilirubin.total [Presence] in Urine by Test strip Finding of bilirubin in urine
Ketones [Mass/volume] in Urine by Test strip 2.6 0 - 4 mg/dL
Ketones [Presence] in Urine by Test strip Urine ketone test = ++
Specific gravity of Urine by Test strip 1.0 L 1.005 - 1.030 {nominal}
pH of Urine by Test strip 6.0 5.0 - 8.0 pH
Protein [Mass/volume] in Urine by Test strip 236.3 H 0 - 20 mg/dL
Protein [Presence] in Urine by Test strip Urine protein test = ++
Nitrite [Presence] in Urine by Test strip Urine nitrite negative
Hemoglobin [Presence] in Urine by Test strip Urine blood test = negative
Leukocyte esterase [Presence] in Urine by Test strip Urine leukocyte test negative
Hemoglobin A1c/Hemoglobin.total in Blood 3.4 L 4.0 - 5.6 %
Glucose [Mass/volume] in Blood 95.2 70 - 140 mg/dL
Urea nitrogen [Mass/volume] in Blood 18.4 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 2.2 H 0.6 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 9.5 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 137.7 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 5.1 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 106.9 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 21.6 L 22 - 29 mmol/L

Device Use

Device Date (since)
Home nebulizer (physical object) 19-Dec-2007
Blood glucose meter (physical object) 28-Feb-1962