Medical Records M A
Resume:
<ClinicalDocument xmlns="urn:hl7-org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:sdtc="urn:hl7-
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<title>Ambulatory Summary</title>
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<addr use="HP">
<streetAddressLine>6573 NW 43rd Ct</streetAddressLine>
<streetAddressLine nullFlavor="NI"/>
<city>Coral Springs</city>
<state>FL</state>
<postalCode>33067-3015</postalCode>
<country>US</country>
</addr>
<telecom use="HP" value="tel:+1-954-***-****"/>
<patient>
<name>
<given>Jeffrey</given>
<given>F</given>
<family>Kopp</family>
</name>
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<languageCode code="eng"/>
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<author>
<time value="20230529175916-0400"/>
<assignedAuthor>
<id root="2.16.840.1.113883.3.564"/>
<addr use="WP">
<streetAddressLine>311 Arsenal St</streetAddressLine>
<streetAddressLine nullFlavor="NI"/>
<city>Watertown</city>
<state>MA</state>
<postalCode>02472</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1-617-***-****"/>
<assignedAuthoringDevice>
<manufacturerModelName>athenahealth</manufacturerModelName>
<softwareName>athenahealth</softwareName>
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<name>athenahealth</name>
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<addr use="WP">
<streetAddressLine>311 Arsenal St</streetAddressLine>
<streetAddressLine nullFlavor="NI"/>
<city>Watertown</city>
<state>MA</state>
<postalCode>02472</postalCode>
<country>US</country>
</addr>
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codeSystemName="NUCC" displayName="Internal Medicine"/>
<addr use="WP">
<streetAddressLine>6864 B FOREST HILL BLVD</streetAddressLine>
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<city>GREENACRES</city>
<state>FL</state>
<postalCode>33413</postalCode>
<country>US</country>
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<name>ORLANDO CUADRA</name>
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codeSystemName="LOINC"/>
<title>Allergies</title>
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<table>
<thead>
<tr>
<th>Code</th>
<th>Code System</th>
<th>Name</th>
<th>Reaction</th>
<th>Severity</th>
<th>Status</th>
<th>Onset</th>
</tr>
</thead>
<tbody>
<tr>
<td>2670</td>
<td>RxNorm</td>
<td><content
ID="allergy1allergen">Codeine</content></td>
<td><content
ID="allergy1reaction1 xA0;</content></td>
<td><content
ID="allergy1severity1 xA0;</content></td>
<td>Active</td>
<td><content ID="allergy1onset xA0;</content></td>
</tr>
</tbody>
</table>
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codeSystemName="RxNorm" displayName="codeine">
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<reference value="#allergy1allergen"/>
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codeSystemName="ATHENA_ALLERGYID" displayName="CODEINE"/>
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codeSystemName="LOINC" displayName="History of Medication Use"/>
<title>Medications</title>
<text>
<table>
<thead>
<tr>
<th>Name</th>
<th>Status</th>
<th>Start Date</th>
<th>Stop Date</th>
<th> </th>
<th> </th>
</tr>
</thead>
<tbody>
<tr>
<td styleCode="Botrule"><content ID="Med1">amlodipine 5 mg
tablet<br/> QD</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med2">amoxicillin 500 mg
tablet<br/> TAKE TWO TABLETS BY MOUTH TO START THEN TAKE ONE TABLET BY MOUTH EVERY
8 HOURS UNTIL GONE</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med3">aspirin 81 mg
tablet,delayed release<br/> Take 1 tablet every day by oral route.</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med4">betamethasone,
augmented 0.05 % topical cream</content></td>
<td styleCode="Botrule">Completed</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">09/16/2020</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med5">Brilinta 90 mg
tablet<br/> Take 1 tablet twice a day by oral route.</content></td>
<td styleCode="Botrule">Completed</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">09/30/2020</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med6">clopidogrel 75 mg
tablet<br/> TAKE ONE TABLET BY MOUTH ONE TIME DAILY</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med7">ezetimibe 10 mg
tablet</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med8">hydrochlorothiazide
12.5 mg tablet<br/> TAKE ONE TABLET BY MOUTH ONE TIME DAILY</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med9">hydrocodone 10 mg-
acetaminophen 325 mg tablet</content></td>
<td styleCode="Botrule">Completed</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">09/30/2020</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med10">hydrocodone 5 mg-
acetaminophen 325 mg tablet<br/> TAKE ONE TABLET BY MOUTH EVERY 6 TO 8 HOURS AS
NEEDED FOR PAIN</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med11">ketoprofen 75 mg
capsule<br/> Take 1 capsule every 8 hours by oral route.</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med12">losartan 100 mg
tablet<br/> TAKE ONE TABLET BY MOUTH ONE TIME DAILY</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med13">metoprolol tartrate
25 mg tablet<br/> TAKE ONE TABLET BY MOUTH TWICE A DAY</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med14">metoprolol tartrate
50 mg tablet</content></td>
<td styleCode="Botrule">Completed</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">09/30/2020</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med15">multivitamin<br/> 1
tablet daily</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med16">ofloxacin 0.3 % ear
drops</content></td>
<td styleCode="Botrule">Completed</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">11/14/2017</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med17">Omega 3<br/> 1 tablet
daily</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med18">paroxetine 10 mg
tablet</content></td>
<td styleCode="Botrule">Completed</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">11/14/2017</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med19">paroxetine 20 mg
tablet</content></td>
<td styleCode="Botrule">Completed</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">11/14/2017</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med20">paroxetine 40 mg
tablet</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med21">prednisolone sodium
phosphate 15 mg/5 mL (3 mg/mL) oral solution</content></td>
<td styleCode="Botrule">Completed</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">11/14/2017</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med22">prednisone 20 mg
tablet</content></td>
<td styleCode="Botrule">Completed</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">09/16/2020</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med23">rosuvastatin 10 mg
tablet</content></td>
<td styleCode="Botrule">Active</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">Not available</td>
</tr>
<tr>
<td styleCode="Botrule"><content ID="Med24">Suprep Bowel Prep Kit
17.5 gram-3.13 gram-1.6 gram oral solution<br/> Take by oral route as
directed</content></td>
<td styleCode="Botrule">Completed</td>
<td styleCode="Botrule xA0;</td>
<td styleCode="Botrule">09/16/2020</td>
</tr>
<tr>
<td><content ID="Med25">valsartan 160 mg-hydrochlorothiazide 12.5
mg tablet<br/> Take 1 tablet every day by oral route for 30 days.</content></td>
<td>Completed</td>
<td> </td>
<td>09/16/2020</td>
</tr>
</tbody>
</table>
</text>
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<low nullFlavor="NI"/>
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<consumable>
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<text><reference value="#Med2"/>TAKE TWO TABLETS BY MOUTH TO START
THEN TAKE ONE TABLET BY MOUTH EVERY 8 HOURS UNTIL GONE</text>
<statusCode code="completed"/>
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<low nullFlavor="NI"/>
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<code code="308192" displayName="amoxicillin 500 MG Oral
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<translation code="208741" codeSystemName="FDB MEDID"/>
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<name>amoxicillin 500 MG Oral Tablet</name>
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<text><reference value="#Med3"/>Take 1 tablet every day by oral
route.</text>
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<manufacturedProduct classCode="MANU">
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<name>aspirin 81 MG Delayed Release Oral Tablet</name>
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<reference value="#Med4"/>
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<statusCode code="completed"/>
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<high value="20200916"/>
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<manufacturedProduct classCode="MANU">
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<code code="848176" displayName="Augmented betamethasone 0.5
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<reference value="#Med4"/>
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<translation code="185960" codeSystemName="FDB MEDID"/>
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<name>Augmented betamethasone 0.5 MG/ML Topical Cream</name>
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</manufacturedProduct>
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route.</text>
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<manufacturedProduct classCode="MANU">
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<reference value="#Med5"/>
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<translation code="565258" codeSystemName="FDB MEDID"/>
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<name>ticagrelor 90 MG Oral Tablet [Brilinta]</name>
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<entry>
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<text><reference value="#Med6"/>TAKE ONE TABLET BY MOUTH ONE TIME
DAILY</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="309362" displayName="clopidogrel 75 MG Oral Tablet"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#Med6"/>
</originalText>
<translation code="200710" codeSystemName="FDB MEDID"/>
</code>
<name>clopidogrel 75 MG Oral Tablet</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act moodCode="INT" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<code code="311401005" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Patient Education"/>
<text/>
<statusCode code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration moodCode="INT" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="0e706dfa-fe6c-11ed-bcf2-127741b0748a"/>
<text>
<reference value="#Med7"/>
</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="349556" displayName="ezetimibe 10 MG Oral Tablet"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#Med7"/>
</originalText>
<translation code="446639" codeSystemName="FDB MEDID"/>
</code>
<name>ezetimibe 10 MG Oral Tablet</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act moodCode="INT" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<code code="311401005" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Patient Education"/>
<text/>
<statusCode code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration moodCode="INT" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="0e70beae-fe6c-11ed-8a15-127741b0748a"/>
<text><reference value="#Med8"/>TAKE ONE TABLET BY MOUTH ONE TIME
DAILY</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="429503" displayName="hydrochlorothiazide 12.5 MG
Oral Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#Med8"/>
</originalText>
<translation code="549792" codeSystemName="FDB MEDID"/>
</code>
<name>hydrochlorothiazide 12.5 MG Oral Tablet</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act moodCode="INT" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<code code="311401005" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Patient Education"/>
<text/>
<statusCode code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration moodCode="INT" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="0e7113c2-fe6c-11ed-ac80-127741b0748a"/>
<text>
<reference value="#Med9"/>
</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low nullFlavor="NI"/>
<high value="20200930"/>
</effectiveTime>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="856999" displayName="acetaminophen 325 MG /
hydrocodone bitartrate 10 MG Oral Tablet" codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
<reference value="#Med9"/>
</originalText>
<translation code="204978" codeSystemName="FDB MEDID"/>
</code>
<name>acetaminophen 325 MG / hydrocodone bitartrate 10 MG Oral
Tablet</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act moodCode="INT" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<code code="311401005" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Patient Education"/>
<text/>
<statusCode code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration moodCode="INT" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="0e7163e0-fe6c-11ed-b40d-127741b0748a"/>
<text><reference value="#Med10"/>TAKE ONE TABLET BY MOUTH EVERY 6 TO
8 HOURS AS NEEDED FOR PAIN</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="857002" displayName="acetaminophen 325 MG /
hydrocodone bitartrate 5 MG Oral Tablet" codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
<reference value="#Med10"/>
</originalText>
<translation code="178036" codeSystemName="FDB MEDID"/>
</code>
<name>acetaminophen 325 MG / hydrocodone bitartrate 5 MG Oral
Tablet</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act moodCode="INT" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<code code="311401005" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Patient Education"/>
<text/>
<statusCode code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration moodCode="INT" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="0e71b43a-fe6c-11ed-a2a6-127741b0748a"/>
<text><reference value="#Med11"/>Take 1 capsule every 8 hours by oral
route.</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<effectiveTime operator="A" xsi:type="PIVL_TS"
institutionSpecified="false">
<period value="8" unit="h"/>
</effectiveTime>
<doseQuantity value="1" unit="capsule(s)"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="197856" displayName="ketoprofen 75 MG Oral Capsule"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#Med11"/>
</originalText>
<translation code="242088" codeSystemName="FDB MEDID"/>
</code>
<name>ketoprofen 75 MG Oral Capsule</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act moodCode="INT" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<code code="311401005" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Patient Education"/>
<text/>
<statusCode code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration moodCode="INT" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="0e7217a4-fe6c-11ed-baea-127741b0748a"/>
<text><reference value="#Med12"/>TAKE ONE TABLET BY MOUTH ONE TIME
DAILY</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="979480" displayName="losartan potassium 100 MG Oral
Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#Med12"/>
</originalText>
<translation code="286047" codeSystemName="FDB MEDID"/>
</code>
<name>losartan potassium 100 MG Oral Tablet</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act moodCode="INT" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<code code="311401005" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Patient Education"/>
<text/>
<statusCode code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration moodCode="INT" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="0e726b82-fe6c-11ed-9347-127741b0748a"/>
<text><reference value="#Med13"/>TAKE ONE TABLET BY MOUTH TWICE A
DAY</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="866924" displayName="metoprolol tartrate 25 MG Oral
Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
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