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

Patient
Name: Musatti, Gianna
DOB: 17-MAR-1952 (Age: 73)
Gender: female
ID: 7618-900219-9 (ECI)
Author
Dr. Ping, Hel
Patient summary Document
European Patient Summary
Report Date: 28-OCT-2024

Problem list

Condition Onset Date Status
Alzheimer's disease 28-Oct-2024 active
Osteoporosis 28-Jul-2008 active
Dependent drug abuse 09-Aug-1995 active
Impacted molars 14-Dec-1990 active
Chronic intractable migraine without aura 05-Jul-1990 active
Prediabetes 06-Aug-1973 active

Medication list

No known medications

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 28-Oct-2024
Clostridium tetani toxoid antigen adsorbed only vaccine product 30-Sep-2019

Procedure History list

Procedure Date Reason
Pre-discharge assessment 01-Sep-2023 -
Discharge from skilled nursing facility (procedure) 01-Sep-2023 -
Occupational therapy 31-Aug-2023 -
Care regimes assessment 31-Aug-2023 -
Professional / ancillary services care 31-Aug-2023 -
Nursing care/supplementary surveillance 31-Aug-2023 -
Radiography of wrist 30-Aug-2023 -
History AND physical examination 30-Aug-2023 -
Bone immobilization 30-Aug-2023 Fracture subluxation of wrist
Initial patient assessment 30-Aug-2023 -
Development of individualized plan of care 30-Aug-2023 -
Patient discharge 22-Jun-2023 -
Hospice care 21-Jun-2023 -
Notifications 05-Jun-2023 -
Certification procedure 05-Jun-2023 -

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
? active ?

Care Plan

Active Planned Care / Goals Start Date Reason
Dementia management 28-Oct-2024 Alzheimer's disease (disorder)
  • Maintain current level of cognitive function as long as possible
  • Preserve ability to perform basic activities of daily living (ADLs)
  • Minimize frequency and severity of behavioral disturbances
  • Achieve at least 90% adherence to prescribed dementia medications
Care plan 29-Jan-2001 -
Diabetes self management plan 06-Aug-1973 Prediabetes
  • Patient will implement and maintain a diabetes self-management plan to reduce risk of progression to diabetes.
Immunization Recommendation Due Date Reason
Vaccine product containing only Influenza virus antigen (medicinal product) 01-Oct-2025 Annual seasonal influenza vaccination

Vital Signs

Vital Signs 2024-10-28 2023-10-23
Body Height 169.3 cm 169.3 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 3 {score} 4 {score}
Body Weight 86.4 kg 86.4 kg
Body mass index (BMI) [Ratio] 30.1 kg/m2 30.1 kg/m2
Diastolic Blood Pressure 80 mm[Hg] 76 mm[Hg]
Systolic Blood Pressure 91 mm[Hg] 100 mm[Hg]
Heart rate 64 /min 86 /min
Respiratory rate 13 /min 14 /min

Relevant diagnostic tests/laboratory data

Recent Lab Observations 28-OCT-2024 Reference Range Unit
Hemoglobin A1c/Hemoglobin.total in Blood 6.0 4 - 6 %
Glucose [Mass/volume] in Blood 73.5 70 - 140 mg/dL
Urea nitrogen [Mass/volume] in Blood 18.2 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 0.8 0.6 - 1.1 mg/dL
Calcium [Mass/volume] in Blood 9.4 8.5 - 10.4 mg/dL
Sodium [Moles/volume] in Blood 140.6 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.9 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 103.7 98 - 108 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 22.4 22 - 29 mmol/L

Device Use

Device Date (since)
Blood glucose meter (physical object) 06-Aug-1973