Introduction

This scenario is an example referral note where the content of the referral note which includes "full" C-CDA 2.1 content.

Nora Watters is a 55 year old who was diagnosed with hypertension in 2010. She had recently been admitted to hospital for chest pains but was discharged later that day. Soon afterwards, she started to experience dizzy spells and make an appointment with her doctor, William Kincaid. Dr. Kincaid suggests following up with a local cardiologist and with Nora's agreement refers her to Dr. Stephen Moores for additional assessment.

Header Data

  • Patient
  • Nora Watters
  • Race: White
  • Ethnicity: Not Hispanic or Latin
  • Language: English
  • DOB: April 30, 1960
  • ID: 111-222-345
  • Address: 1605 Front Street North, Wyandotte, MI 48192
  • Home Phone: (734) 555-8888
  • Referring Physician
  • Dr. WilliamKincaid
  • Address: 13280 Northline Rd, Southgate, MI 48195
  • Phone: (734) 555-9999
  • Receiving Physician
  • Dr. Stephen Moores
  • Referral Date: December 21, 2015

Sections

Allergies and Intolerances

  • Aspirin (anaphylaxis) since April 1, 2005

Assessment and Plan

Patient complains of chest pains and occasional dizziness. Recommend referral to cardiologist for further assessment and diagnosis. ECG ordered on December 15, 2015.

Medications

  • December 4, 2015: Amlodipine - 5mg daily

Problem

  • Chest Pain since November 25, 2015
  • Hypertension since April 15, 2010

Reason for Referral

Assessment and treatment options

Advance Directives

The patient wishes to donate their organs

Family History

Thepatient's father and grandfather both had heart attacks.

Functional Status

Patient walks with a cane (observed November 20, 2015)

General Status

Patient has a pleasant demeanor and is of average height and weight.

History of Past Illness

Hypertension diagnosed in 2010

History of Present Illness

Admitted to General Hospital on November 25, 2015 for chest pain and discharged later that day.

Immunizations

The patient had a flu shot in the fall and Tdap booster last year

  • November 2, 2015 - Flu
  • June 2, 2014 - Tdap

Medical Equipment

February 28, 2013:AGC Knee System Model:155308

Mental Status

The patient has normal cognitive functions as determined during interview on November 25, 2015

Nutrition

The patient is well nourished and has been following a low-sodium diet for the past 6 months.

Physical Exam

Chest exam was unremarkable

Procedures

The patient had a knee replacement two years ago

  • February 18, 2013 - Knee replacement

Results

Lipid panel was ordered on December 15, 2015. Results are normal.

  • December 15, 2015 - Triglycerides Serum of 140 mg/dL
  • December 15, 2015 - LDL of 95 mg/dL
  • December 15, 2015 - HDL of 60 mg/dL

Review of Systems

  • Occasional dizziness
  • No nausea or vomiting
  • No blurred vision
  • Some difficulty breathing while exercising

Social History

The patient is a former smoker

Vital Signs

  • December 1, 2015 - Blood pressure of 132/85 mmHg
  • December 1, 2015 - Height of 163 cm
  • December 1, 2015 - Weight of 68.5 kg

January 2016 HL7 Implementation-A-Thon / 1