Initial Public Health Case Report
Joseph Patient
Patient Identifiers
PT-470127 Meaningless identifier, not to be used for any actual entities. Examples only.
222-22-2222 United States Social Security Number

About

Date of Birth
07/30/1989
Sex
Male
Race
American Indian or Alaska Native
Ethnicity
Not Hispanic or Latino

Contact

Home

2222 Home Street

Sacramento, CA

94203, US

tel: (Primary Home) 555-555-2003
email: (Primary Home) jose@email.com

Emergency Contact

Mr Emer Contact
()

Contact

tel: (Mobile Contact) +1-334-304-2665

Author

Time:
05/5/2020, 11:05
OID: 2.16.840.1.113883.3.72.5.20

Contact

Work Place

1234 Facility Drive

Sacramento, CA

94203

tel: (Work Place) 555-777-0123
fax: (Work Place) 555-777-0987

Encounter

Identifier
9937016 OID: 2.16.840.1.113883.19
Type
inpatient encounter
Date
From: 05/13/2020
To: 05/13/2020
Location
Hospital

Responsible Party

Carmen SanDiego, MD of Sacramento Hospital

Contact

Home

1234 Provider Street

Sacramento, CA

94203, US

tel: (Work Place) 555-777-0123
fax: (Work Place) 555-777-0987

Encounters

EncounterDate(s)Location
inpatient encounter05/13/2020Sacramento Hospital

  • *** In the table below, row entries with values under RCTC columns triggered this Electronic Initial Case Report (eICR)

    Problem TypeProblemDate(s)CodeCodeSystemRCTC OID ***RCTC Version ***
    DiagnosisCoronavirus as the cause of diseases classified elsewhere05/14/2020B97.2ICD-102.16.840.1.114222.4.11.750820200429

History of Present Illness

recent travel for vacation to Wuhan China from April 22, 2020 to May 5, 2020;

Medications Administered

MedicationDirectionsDoseDurationRoute
Remdesivir 100 mg Injection100 mg every day for 4 days100 mgMay 13 11:60IM

Problem List

ConcernConcern StatusDate(s)
Problemactive05/13/2020

  • *** In the table below, row entries with values under RCTC columns triggered this Electronic Initial Case Report (eICR)

    Problem TypeProblemDate(s)CodeCode SystemRCTC OID ***RCTC Version ***
    symptomDifficulty Breathing )finding)05/13/2020230145002SNOMED-CT
    symptom

Reason for visit

recent travel for vacation to Wuhan China from April 22, 2020 to May 5, 2020

Results

Results PanelDate(s)
SARS coronavirus 2 N gene [Presence] in Unspecified specimen by Nucleic acid amplification using primer-probe set N2

  • *** In the table below, row entries with values under RCTC columns triggered this Electronic Initial Case Report (eICR)

    TestLab Test RCTC OID ***Lab Test RCTC Version ***OutcomeDate(s)Lab Result RCTC OID ***Lab Result RCTC Version ***
    SARS coronavirus 2 N gene [Presence] in Unspecified specimen by Nucleic acid amplification using primer-probe set N2Detected (qualifier value)05/13/2020

Plan of Treatment

*** In the table below, row entries with values under RCTC columns triggered this Electronic Initial Case Report (eICR)

Lab Test OrderCodeCodeSystemRCTC OID ***RCTC Version ***Ordered Date
SARS coronavirus 2 N gene [Presence] in Unspecified specimen by Nucleic acid amplification using primer-probe set N294308-4 LOINC05/13/2020

Social History

Birth SexValueDate
Sex Assigned At BirthMale07/30/1989
Social History Observation TypeValueDates(s)
Occupation / Employment detailsSales
Travel History: Date(s)NotesLocation
04/22/2020 - 05/05/2020recent travel for vacation to Wuhan China from April 22, 2020 to May 5, 2020

Immunizations

NameAdministration DatesStatus
influenza, intradermal, quadrivalent, preservative free, injectable Nov 2019Completed

Document maintained by

Sacramento Hospital

Contact

Work Place

1234 Facility Drive

Sacramento, CA

94203

tel: (Work Place) 555-777-0123

Document Information

Document IdentifierDocument Created
OID: 38e6a983-38ad-484f-a7d2-b294cdbe543505/5/2020, 11:05