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Good Hospital

Author	Doctor Good Smith (General Medical Practitioner)
Phone	0345754566
Discharge To	Administrative Discharge
Discharge From	Ward B

Health Profile

This section may contain the following subsections Adverse Reactions and Alerts.

Adverse Reactions (Health Profile > Adverse Reactions)

Adverse Reactions
Substance/Agent	Manifestations	Adverse Reaction Type
Penicillin	Urticaria Trunk Leg Nausea and vomiting	Urticaria
Metoprolol	Chronic obstructive airways disease NOS	Positive Infinity

Alerts (Health Profile > Alerts)

At risk for infection (Medical)
At risk for infection (Medical)

Event

This section may contain the following subsections Problems/Diagnoses This Visit, Clinical Interventions Performed This Visit and Clinical Synopsis and Diagnostic Investigations.

Clinical Synopsis (Event > Clinical Synopsis)

Clinical Synopsis
Clinical Synopsis
Admitted for elective, right Total Knee Replacement (cemented prosthesis). Day 3, developed bilateral basal atelectasis. The FBC showed high WCC (20.0) and high neutrophils (16.0). Commenced on doxycycline and chest physio. Due to mild anaemia prior to surgery and subsequent operative blood loss, required a blood transfusion of three units. Subsequently made steady progress, regaining good mobility in his knee and is able to mobilise with the aid of a stick. Right knee Xray showed no fracture or dislocation, with the total knee prosthesis well positioned post surgery.

Problems/Diagnoses This Visit (Event > Problems/Diagnoses This Visit)

Type	Description
Accidental bisacodyl overdose	Infection by Spirura
Principal Diagnosis	Systemic aspergillosis

Clinical Interventions Performed This Visit (Event > Clinical Interventions Performed This Visit)

Clinical Intervention Description
Value(s)
Primary cemented total knee replacement
Insulin C-peptide measurement
Transfusion of packed red blood cells

Diagnostic Investigations (Event > Diagnostic Investigations)

This section may contain the following subsections Pathology Test Result and Imaging Examination Result.

Pathology Test Result (Event > Diagnostic Investigations > Pathology Test Result)

Pathology Test Result
Field	Value
Test Name	Pathology Test Result
Result Status	Final
Date Time	19 Aug 2014 13:28+1000
Comment	test

GLUCOSE - FASTING         BLOOD GLUCOSE                 10.8 * mmol/L         (3.9-6.0)      Values for Diagnosis of Diabetes Mellitus and other Hyperglycaemia       DIABETES MELLITUS (DM)         Fasting                &gt; 6.9  mmol/L         or 2 hrs post load     &gt; 11.0 mmol/L       IMPAIRED FASTING GLYCAEMIA (IFG)         Fasting                 &gt; 6.0 mmol/L and &lt; 7.0 mmol/L    Date Collected  : 07/07/2005    Time Collected  : 12:15                 Reference    Episode         : 1    Units      Range    ==============    ==========    GLUCOSE - FASTING    BLOOD GLUCOSE   : 10.8 *     mmol/L     (3.9-6.0)

Pathology Test Result (Event > Diagnostic Investigations > Pathology Test Result)

PhysicalDetails 3

physicalDetailsImage X-Ray

AnatomicalSite X-Ray

PhysicalDetails 1

Pathology Test Result(s)
Result DateTime	Result Name	Diagnostic Service	Overall Result Status	Clinical Information	Diagnosis	Conclusion	Comment	Result Representation
19 Aug 2014 13:28+1000	Pathology Test Result 2	Chemistry	Final	Hepatitus	Normal Abnormal	testResultGroup-Conclusion	testResultGroup-Comment	Lipase 150 U/L (RR < 70)

Test Request Details
Laboratory Test Result Identifier	Test Requested Name(s)
Laboratory Test Result Identifier	Serum Blood pressure
Laboratory Test Result Identifier	Heart Heart

Pathology Test Specimen Detail
Received DateTime	Identifier	Parent Identifier	Container	Physical Description	Physical Details	Sampling Preconditions	Collection Date	Collection Procedure	Collection Setting	Image / File
21 Aug 2014 13:28+1000	d33dc71d-ecb2-46b3-8048-6fa65d8635b9	e282e9b7-5315-4dbb-9a3c-f6735ae47526	AZH45218964	Urine sample	20kg	fasting	9 Aug 2014 13:28+1000	Urine sample	Ward 3B	See above..

Result Group Specimen Detail
Received DateTime	Identifier	Parent Identifier	Container	Tissue Type	Physical Description	Physical Details	Sampling Preconditions	Collection Date	Collection Procedure	Collection Setting	Image / File
21 Aug 2014 13:28+1000	65f65a16-e2c4-4a77-971f-0a90d0628a4b	236fb624-2419-4094-8943-b850bf1f7b32	CNH45218964	Tissue	physicalDetails-Description	6ml	fasting	30 Jul 2014 13:28+1000	blood draw	Ward 1A	See above..

Test Result Group
Group Name	Result Name	Result Value	Status	Reference Range Details	Result Comment	Reference Range Guidance	Result Status
Chemistry Studies (Set)	Sodium	12.88 ml	Normal	High High: 50ml Low: 100mlLow High: 10ml Low: 20ml	Sodium test result comments More comments Another comment	Reference range guidance comments for Sodium; eg. the quantity should be between the high and low values	Interim
Chemistry Studies (Set)	Blood	5 km	Normal	High High: 50ml Low: 100mlLow High: 10ml Low: 20ml	Blood test result comments More comments Another comment	Reference range guidance comments for blood; eg. the quantity should be between the high and low values	Final

Result Group Specimen Detail
Received DateTime	Identifier	Parent Identifier	Container	Physical Description	Physical Details	Sampling Preconditions	Collection Date	Collection Procedure	Collection Setting	Image / File
21 Aug 2014 13:28+1000	8faab9f5-e38d-4cf9-bb2e-d4df4ea0ed89	d2b49ef3-6c32-4ee0-84ae-f6dd285d78d3	AZH45218964	Urine sample	20kg	fasting	9 Aug 2014 13:28+1000	Urine sample	Ward 3B	See above..

Test Result Group
Group Name	Result Name	Result Value	Status	Reference Range Details	Result Comment	Reference Range Guidance	Result Status
Positive Infinity	Blood	5 km	Normal	High High: 2psi Low: 150psiLow High: 15psi Low: 200psi	Heart test result comments More comments Another comment	Reference range guidance comments for heart; eg. the quantity should be between the high and low values	Final

Anatomical Site(s)
Identifier	Description	Location	Side	Image / File
d33dc71d-ecb2-46b3-8048-6fa65d8635b9	Arm	Zygomatic arch structure	Right
65f65a16-e2c4-4a77-971f-0a90d0628a4b	Arm	Dacryocyte	Left	See above..
8faab9f5-e38d-4cf9-bb2e-d4df4ea0ed89	Arm	Sterile abscess	Unilateral left

Imaging Examination Result (Event > Diagnostic Investigations > Imaging Examination Result)

X-Ray - Right Arm

X-Ray

X-Ray - Left Femur

4 X-Ray

5 X-Ray

6 X-Ray

Anatomical Site(s)
Description	Location	Side	Image / File
Arm	Subcutaneous tissue structure of lateral surface of index finger	Right	See above..

Imaging Examination Result Details
Field	Value
Imaging Examination Result Date Time	19 Aug 2014 13:28+1000
Result name	Image test 1
Modality	Ultrasound
Result Status	Final
Clinical Information	Patient pregnant. Confirm dates. Estimate from LNMP 18 weeks.
Findings	Normal obstetric ultrasound with foetal biometry indicating getational age of 18W0D.
Result Representation	ResultRepresentation

Result Group(s)
Result Group	Name	Value	Status	Range	Comment
ultrasound scan - obstetric	ultrasound scan	Ultrasound	Normal	Normal range High: 17ml Low: 13mlHigh High: 50ml Low: 100ml	Femur measured during ultrasound scan. Legs measured during ultrasound scan.

Anatomical Site(s)
Description	Location	Side	Image / File
Femur Length	Subcutaneous tissue structure of lateral surface of index finger	Left	See above..

Result Group(s)
Result Group	Name	Value	Status	Range	Comment
Ultrasound	Ultrasound	Ultrasound	Normal	Normal range High: 15ml Low: 18mlHigh High: 60ml Low: 110ml	Waist measured during ultrasound scan. Waist measured during ultrasound scan.

Anatomical Site(s)
Description	Location	Side	Image / File
Arm	Subcutaneous tissue structure of lateral surface of index finger	Right	See above..

Examination Request(s) - Image Details
Requested Examination Name	Image Date	Identifiers	Subject Position	Image / File
A/U Obstetric - Dating another name	21 Aug 2014 13:28+1000	DICOM Study ID: Accession Number Group: 0008 Element: 0050 Report ID: 3355552BHU-23.3 DICOM Series ID: Series Identifier	Supine	See above..
A/U Skin - Stuff another name	21 Aug 2014 13:28+1000 21 Aug 2014 13:28+1000	DICOM Study ID: Accession Number Group: 0008 Element: 0050 Report ID: 3355552BHU-23.3 DICOM Series ID: Series IdentifierDICOM Series ID: Series Identifier	Sublime Head	See above..

Imaging Examination Result (Event > Diagnostic Investigations > Imaging Examination Result)

X-Ray - Right Arm

X-Ray

X-Ray - Left Femur

4 X-Ray

5 X-Ray

6 X-Ray

Anatomical Site(s)
Description	Location	Side	Image / File
Arm	Subcutaneous tissue structure of lateral surface of index finger	Right	See above..

Imaging Examination Result Details
Field	Value
Imaging Examination Result Date Time	19 Aug 2014 13:28+1000
Result name	Image test 2
Modality	Ultrasound
Result Status	Final
Clinical Information	Patient pregnant. Confirm dates. Estimate from LNMP 18 weeks.
Findings	Normal obstetric ultrasound with foetal biometry indicating getational age of 18W0D.
Result Representation	ResultRepresentation

Result Group(s)
Result Group	Name	Value	Status	Range	Comment
ultrasound scan - obstetric	ultrasound scan	Ultrasound	Normal	Normal range High: 17ml Low: 13mlHigh High: 50ml Low: 100ml	Femur measured during ultrasound scan. Legs measured during ultrasound scan.

Anatomical Site(s)
Description	Location	Side	Image / File
Femur Length	Subcutaneous tissue structure of lateral surface of index finger	Left	See above..

Result Group(s)
Result Group	Name	Value	Status	Range	Comment
Ultrasound	Ultrasound	Ultrasound	Normal	Normal range High: 15ml Low: 18mlHigh High: 60ml Low: 110ml	Waist measured during ultrasound scan. Waist measured during ultrasound scan.

Anatomical Site(s)
Description	Location	Side	Image / File
Arm	Subcutaneous tissue structure of lateral surface of index finger	Right	See above..

Examination Request(s) - Image Details
Requested Examination Name	Image Date	Identifiers	Subject Position	Image / File
A/U Obstetric - Dating another name	21 Aug 2014 13:28+1000	DICOM Study ID: Accession Number Group: 0008 Element: 0050 Report ID: 3355552BHU-23.3 DICOM Series ID: Series Identifier	Supine	See above..
A/U Skin - Stuff another name	21 Aug 2014 13:28+1000 21 Aug 2014 13:28+1000	DICOM Study ID: Accession Number Group: 0008 Element: 0050 Report ID: 3355552BHU-23.3 DICOM Series ID: Series IdentifierDICOM Series ID: Series Identifier	Sublime Head	See above..

Diagnostic Investigation (Event > Diagnostic Investigation)

Other Test Result
Field	Value
Report Date	19 Aug 2014 13:28+1000
Report Name	Report with Attachment
Report Status	Interim
Report Content	Path File

Diagnostic Investigation (Event > Diagnostic Investigation)

Other Test Result
Field	Value
Report Date	19 Aug 2014 13:28+1000
Report Name	Report with Text
Report Status	Interim
Report Content	Report Content Text

Medications

This section may contain the following subsections Current Medications On Discharge and Ceased Medications.

Current Medications On Discharge (Medications > Current Medications On Discharge)

Current Medications On Discharge
Medication	Directions	Dispensed	Clinical Indication	Duration	Change Status	Change Description	Change Reason	Comments
paracetamol 500 mg + codeine phosphate 30 mg tablet	1 tablet once daily oral	2 tablets	Pneumonia	21 Aug 2014 13:28+1000 -> 26 Aug 2014 13:28+1000	New	Dose decreased from 2 tablet 4 a day	Due to hypotension	Additional Comments
paracetamol 500 mg + codeine phosphate 30 mg tablet	2 tablets daily oral	4 tablets	Stress	21 Aug 2014 13:28+1000 -> 3 Jan 2016 13:28+1000	New	Dose decreased from 1 tablet Twice a day	Stress

Ceased Medications (Medications > Ceased Medications)

Ceased Medications
Medication	Change Made	Change Status	Change Reason
paracetamol 500 mg + codeine phosphate 30 mg tablet	Changes Made	Ceased	No longer required
paracetamol 500 mg + codeine phosphate 30 mg tablet	Changes Made	Ceased	No longer needed

Plan

This section may contain the following subsections Arranged Services and Record Of Recommendations And Information Provided.

Arranged Services (Plan > Arranged Services)

Arranged Service
Description	Commencement	Status	Name	Details	Phone	Email
Orthopaedic outpatient clinic appointment for 4 weeks post-discharge progress review	21 Aug 2014 13:28+1000 -> 10 Sep 2014 13:28+1000	Appointment	Dr Jane ANDERSON	Super Healthy Hospital	0345754566 (WorkPlace), 0414754566 (WorkPlace)	Jane@Hospital.com
Orthopaedic outpatient clinic appointment for 4 weeks post-discharge progress review	21 Aug 2014 13:28+1000 -> 20 Oct 2014 13:28+1000	Appointment	Bay Hill Hospital	Hospital	0345754566 (WorkPlace)	BayHill@BayHill.com.au

Record of Recommendations and Information Provided (Plan > Record of Recommendations and Information Provided)

Recommendation
Description	Name	Details	Phone	Email
Please remove the staples on Aug 24 2010. Please ensure aspirin is recommenced 3 days post discharge. Please follow-up anaemia.	Doctor Alison HODGERS	Super Healthy Hospital	0345754566 (WorkPlace)	Alison@Hodgers.com
Please remove from waiting list	Super Healthy Hospital	Hospital	0345754566 (WorkPlace)	SuperHealthyHospital@Hospital.com

Information Provided
Value
Patient was given a brochure explaining the expected post-op recovery following a total knee replacement. The physiotherapist provided a list of home exercises. The good prognosis for return to activity was discussed with the patient - likely to be able to walk with a stick at six weeks.

Administrative Observations

Demographic Data
Field	Value
Date of Birth is Calculated From Age	True
Date of Birth Accuracy Indicator	AAA
Age Accuracy Indicator	True
Birth Plurality	3
Age	54y
Date of Death Accuracy Indicator	AAA

ADMINISTRATIVE DETAILS

Encounter Details

Discharge Date	21 Aug 2014 13:28+1000
Discharge To	Administrative Discharge
Discharge From	Ward B
Specialties	Dermatology Paediatric cardiology

Responsible Health Professional At Time Of Discharge

Name	Miss John Middle Smith
Home Address	1 Clinician Street, Nehtaville, QLD, 5555, Australia
Organisation	Super Healthy Hospital
Department	Endocrinology

Facility

Name	Canberra Hospital
Address	No Fixed Address
Phone	0262442229 (Workplace)
Department	Department Name

Patient

Name	Miss Sally Wally GRANT a.k.a. Mr Wally GRANT
Sex	Female
Indigenous Status	Neither Aboriginal nor Torres Strait Islander origin
Date of Birth	21 Aug 1957 (DECEASED)
Status	DECEASED
Deceased Time	21 Aug 2014
IHI	8003 6044 4456 7894
Entitlements	1234567881 (Medicare Benefits)
Local Identifiers	123456 (Croydon GP Centre)
	59501704511 (Individual Medicare Card Number)
Home Address	1 Clinician Street, Nehtaville, NSW, 5555, Australia
Temporary Address	1 Overseas Street, Foreign Land, 12345, New Caledonia
Phone	0345754566 (Workplace)
Email	authen@globalauthens.com (Workplace)

Author

Name	Doctor Good Smith a.k.a. Brother Davey Wong Sir (General Medical Practitioner)
Organisation	Good Hospital
Department	Surgical Ward
Home Address	1 Clinician Street, Nehtaville, QLD, 5555, Australia
Temporary Address	2 Clinician Street, Nehtaville, QLD, 5555, Australia
Phone	0345754566 (Workplace)
Email	authen@globalauthens.com (Workplace)

Clinical Document Details

Document Type	e-Discharge Summary
Creation Date/Time	21 Aug 2014 22:28+1000
Date/Time Attested	21 Aug 2014 13:28+1000
Document ID	2.25.263498878813690208021966154988434320272
Document Set ID	3fb55e43-276d-4c0b-8914-751bdc7ff3b3
Document Version	1
Completion Code	Final

Participants

Name	Contact	Address	Organisation	Department
NominatedPrimaryHealthCareProviderPerson (Nominated Primary Healthcare Provider Person)	Phone: 0345754566 (Workplace)	Work Place: 1 Clinician Street, Nehtaville, QLD, 5555, Australia	Super Healthy Hospital	Endocrinology
OtherParticipant	Phone: 0345754566 (Workplace)	Home Address: Other 1 Clinician Street, Nehtaville, QLD, 5555, Australia	Super Healthy Hospital	Endocrinology

Primary Recipients

Name	Contact	Address	Organisation
Doctor Information Recipient a.k.a. Mr Information Recipient	Phone: 0345754566 (Workplace) Email: authen@globalauthens.com (Workplace)	Home Address: 1 Clinician Street, Nehtaville, QLD, 5555, Australia Temporary Address: 1 Overseas Street, Foreign Land, 12345, Albania	Specialist Clinics

Secondary Recipients

Name	Contact	Address	Organisation
Doctor Information Recipient a.k.a. Mr Information Recipient	Phone: 0345754566 (Workplace) Email: authen@globalauthens.com (Workplace)	Home Address: 1 Clinician Street, Nehtaville, QLD, 5555, Australia Temporary Address: 1 Overseas Street, Foreign Land, 12345, Albania	Specialist Clinics

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