Visit Query Response
Description
The following is the typical format of the response that you would receive for a VisitQuery. Visit details, including visit date, time, and location.Patient information, including patient demographics, such as name, date of birth, gender, and contact information. Diagnoses, including the primary diagnosis and any secondary diagnoses associated with the visit. Procedures, including any procedures performed during the visit. Medications, including current and historical medications administered or prescribed during the visit. Laboratory results, including any relevant lab test results obtained during the visit. Imaging reports, including radiology and other imaging reports, as applicable. Encounter notes or summaries, providing a summary of the visit and any relevant clinical notes documented during the encounter.Care team information, including details of the healthcare providers involved in the visit. Other relevant clinical data, such as vital signs, allergies, immunizations, social history, and family history, as available.
API endpoints for Visit Query Response
Sync REST API Endpoint to call the API: https://{base_url}/api/v1/clinical-summary/visit-query-response.
Async REST API Endpoint to call the API: https://{base_url}/api/v1/endpoint.
Data Model JSON for Visit Query Response
Visit Query Response - Sample Payload
{
"Meta": {
"DataModel": "Clinical Summary",
"EventType": "VisitQueryResponse",
"EventDateTime": "2022-08-16T14:21:20.733Z",
"Test": true,
"Source": {
"ID": "c15b510a-3aa2-4b33-8335-1594014cb5d4",
"Name": "EHR Bridge Dev Tools"
},
"Destinations": [
{
"ID": "949b9ae4-5362-493c-994d-9b2b63f61ead",
"Name": "Visit Query Endpoint"
}
],
"Logs": [
{
"ID": "ec441177-f83c-4a4d-a57a-935e44474ff6",
"AttemptID": "c632ad71-6d8a-4704-8442-cb5bf0a61d9f"
}
],
"Message": {
"ID": 5565
},
"Transmission": {
"ID": 12414
},
"FacilityCode": null
},
"Header": {
"Document": {
"Author": {
"ID": "4356789876",
"IDType": "2.16.840.1.113883.4.6",
"FirstName": "James",
"LastName": "Smith",
"Credentials": [
"MD"
],
"Address": {
"StreetAddress": "123 Main St.",
"City": "San Jose",
"State": "CA",
"ZIP": "53703",
"County": "Santa Clara",
"Country": "USA"
},
"EmailAddresses": [],
"PhoneNumber": {
"Office": "+16085551234"
},
"Type": null,
"Location": {
"Type": null,
"Facility": null,
"Department": null,
"Room": null
}
},
"ID": "75cb4ad4-e5f9-4cd3-8750-eb5050521e0d",
"Locale": "US",
"Title": "Community Health and Hospitals: Annual Physical",
"DateTime": "2012-09-12T00:00:00.000Z",
"Type": "Progress Note",
"TypeCode": {
"Code": "18842-5",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Progress Note"
},
"Confidentiality": {
"Code": "R",
"CodeSystem": "2.16.840.1.113883.5.25",
"CodeSystemName": "Confidentiality",
"Name": "restricted"
},
"Custodian": {
"Identifiers": [],
"Name": null,
"Type": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"Address": {
"StreetAddress": null,
"City": null,
"State": null,
"ZIP": null,
"County": null,
"Country": null
},
"Telecom": []
},
"Visit": {
"StartDateTime": "2022-08-16T14:21:20.728Z",
"EndDateTime": "2022-08-16T14:21:20.728Z",
"Reason": "Annual Physical",
"VisitNumber": "30311442",
"Type": {
"Code": "99202",
"CodeSystem": "2.16.840.1.113883.6.12",
"CodeSystemName": "CPT",
"Name": "Office visit",
"AltCodes": []
},
"Location": {
"Type": "Outpatient Clinic",
"Facility": "RHS Vista Oaks Clinic",
"Department": "Vista Oaks Clinic",
"Room": null
},
"DischargeDisposition": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
}
}
},
"Patient": {
"Identifiers": [
{
"ID": "1234",
"IDType": "2.16.840.1.113883.4.6",
"Type": null
}
],
"Demographics": {
"FirstName": "Myra",
"MiddleName": null,
"LastName": "Jones",
"DOB": "1947-05-01",
"SSN": "123-101-1234",
"Sex": "Female",
"Address": {
"StreetAddress": "1357 Amber Drive",
"City": "San Jose",
"State": "CA",
"County": null,
"Country": "USA",
"ZIP": "97006"
},
"PhoneNumber": {
"Home": "+18162766909",
"Mobile": null
},
"EmailAddresses": [
{
"Address": "12313124@fake.com"
}
],
"Language": null,
"Race": "White",
"RaceCodes": [
{
"Code": "2106-3",
"CodeSystem": "2.16.840.1.113883.6.238",
"CodeSystemName": "CDC Race and Ethnicity",
"Name": "White"
},
{
"Code": "2112-1",
"CodeSystem": "2.16.840.1.113883.6.238",
"CodeSystemName": "CDC Race and Ethnicity",
"Name": "German"
}
],
"Ethnicity": "Hispanic or Latino",
"EthnicGroupCodes": [
{
"Code": "2135-2",
"CodeSystem": "2.16.840.1.113883.6.238",
"CodeSystemName": "CDC Race and Ethnicity",
"Name": "Hispanic or Latino"
},
{
"Code": "2149-3",
"CodeSystem": "2.16.840.1.113883.6.238",
"CodeSystemName": "CDC Race and Ethnicity",
"Name": "Mexican American"
}
],
"Religion": "Christian (non-Catholic, non-specific)",
"MaritalStatus": "Married",
"IsDeceased": false,
"DeathDateTime": null
},
"Organization": {
"Identifiers": [],
"Name": null,
"Type": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"Address": {
"StreetAddress": null,
"City": null,
"State": null,
"ZIP": null,
"County": null,
"Country": null
},
"Telecom": []
}
},
"PCP": {
"ID": null,
"IDType": null,
"FirstName": null,
"LastName": null,
"Credentials": [],
"Address": {
"StreetAddress": null,
"City": null,
"State": null,
"ZIP": null,
"County": null,
"Country": null
},
"EmailAddresses": [],
"PhoneNumber": {
"Office": null
},
"Type": null,
"Location": {
"Type": null,
"Facility": null,
"Department": null,
"Room": null
}
}
},
"AdmissionDiagnosisText": null,
"AdmissionDiagnosis": [],
"AdvanceDirectivesText": "<table width=\"100%\"><thead><tr><th>Directive</th><th>Description</th><th>Verification</th><th>Supporting Document(s)</th></tr></thead><tbody><tr><td>Resuscitation status</td><td ID=\"AD1\">Do not resuscitate</td><td>Dr. Robert Dolin, Nov 07, 1999</td><td><linkHtml href=\"AdvanceDirective.b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3.pdf\">Advance directive</linkHtml></td></tr></tbody></table>",
"AdvanceDirectives": [
{
"Type": {
"Code": "304251008",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Resuscitation",
"AltCodes": []
},
"Code": "304253006",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Do not resuscitate",
"AltCodes": [],
"StartDate": "2011-02-13T05:00:00.000Z",
"EndDate": null,
"ExternalReference": "AdvanceDirective.b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3.pdf",
"VerifiedBy": [
{
"FirstName": "Robert",
"LastName": "Dolin",
"Credentials": "Dr.",
"DateTime": null
}
],
"Custodians": [
{
"FirstName": "Robert",
"LastName": "Dolin",
"Credentials": "Dr.",
"Address": {
"StreetAddress": "21 North Ave.",
"City": "San Jose",
"State": "CA",
"Country": "USA",
"ZIP": "02368"
}
}
]
}
],
"AllergyText": "<table width=\"100%\"><thead><tr><th>Substance</th><th>Reaction</th><th>Severity</th><th>Status</th></tr></thead><tbody><tr><td>Penicillin G benzathine</td><td ID=\"reaction1\">Hives</td><td ID=\"severity1\">Moderate to severe</td><td>Inactive</td></tr><tr><td>Codeine</td><td ID=\"reaction2\">Shortness of Breath</td><td ID=\"severity2\">Moderate</td><td>Active</td></tr><tr><td>Aspirin</td><td ID=\"reaction3\">Hives</td><td ID=\"severity3\">Mild to moderate</td><td>Active</td></tr></tbody></table>",
"Allergies": [
{
"Type": {
"Code": "419511003",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Propensity to adverse reaction to drug",
"AltCodes": []
},
"Substance": {
"Code": "7982",
"CodeSystem": "2.16.840.1.113883.6.88",
"CodeSystemName": "RxNorm",
"Name": "Penicillin G benzathine",
"AltCodes": []
},
"Reaction": [
{
"Code": "28926001",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Rash",
"AltCodes": [],
"Severity": {
"Code": "255604002",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Mild"
},
"Text": null
},
{
"Code": "247472004",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Hives",
"AltCodes": [],
"Severity": {
"Code": "6736007",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Moderate"
},
"Text": null
}
],
"Severity": {
"Code": "6736007",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Moderate"
},
"Criticality": {
"Code": "CRITH",
"CodeSystem": "2.16.840.1.113883.5.1063",
"CodeSystemName": "ObservationValue",
"Name": "High criticality"
},
"Status": {
"Code": "73425007",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Inactive"
},
"StartDate": null,
"EndDate": null,
"Comment": null,
"Comments": [
{
"Text": "Noted when patient took penicillin for ear infection."
}
]
},
{
"Type": {
"Code": "419511003",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Propensity to adverse reaction to drug",
"AltCodes": []
},
"Substance": {
"Code": "2670",
"CodeSystem": "2.16.840.1.113883.6.88",
"CodeSystemName": "RxNorm",
"Name": "Codeine",
"AltCodes": [
{
"Code": "11QV9BS0CB",
"CodeSystem": "2.16.840.1.113883.4.9",
"CodeSystemName": "UNII",
"Name": "Codeine"
}
]
},
"Reaction": [
{
"Code": "267036007",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Shortness of Breath",
"AltCodes": [],
"Severity": {
"Code": "6736007",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Moderate"
},
"Text": null
}
],
"Severity": {
"Code": "6736007",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Moderate"
},
"Criticality": {
"Code": "CRITL",
"CodeSystem": "2.16.840.1.113883.5.1063",
"CodeSystemName": "ObservationValue",
"Name": "Low criticality"
},
"Status": {
"Code": "55561003",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Active"
},
"StartDate": null,
"EndDate": null,
"Comment": null,
"Comments": []
},
{
"Type": {
"Code": "419511003",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Propensity to adverse reaction to drug",
"AltCodes": []
},
"Substance": {
"Code": "1191",
"CodeSystem": "2.16.840.1.113883.6.88",
"CodeSystemName": "RxNorm",
"Name": "Aspirin",
"AltCodes": []
},
"Reaction": [
{
"Code": "247472004",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Hives",
"AltCodes": [],
"Severity": {
"Code": "371923003",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Mild to moderate"
},
"Text": null
}
],
"Severity": {
"Code": "371923003",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Mild to moderate"
},
"Criticality": {
"Code": "CRITU",
"CodeSystem": "2.16.840.1.113883.5.1063",
"CodeSystemName": "ObservationValue",
"Name": "Unable to assess criticality"
},
"Status": {
"Code": "55561003",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Active"
},
"StartDate": null,
"EndDate": null,
"Comment": null,
"Comments": []
}
],
"AssessmentText": "<list><item>Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy.</item><item>Acute on chronic anemia secondary to #1.</item><item>Azotemia, acute renal failure with volume loss secondary to #1.</item><item>Hyperkalemia secondary to #3 and on ACE and K+ supplement.</item><item>Other chronic diagnoses as noted above, currently stable.</item></list>Also, this person has back problems.",
"Assessment": {
"Diagnoses": [
{
"Value": "Displacement of lumbar intervertebral disc without myelopathy",
"DateTime": "2009-11-01T05:00:00.000Z",
"IsNegativeIndicator": false,
"Codes": [
{
"Code": "202708005",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED-CT",
"Name": "Herniated lumbar intervertebral disc"
},
{
"Code": "M51.26",
"CodeSystem": "2.16.840.1.113883.6.90",
"CodeSystemName": "ICD-10",
"Name": "Herniated lumbar intervertebral disc"
}
],
"Comments": []
},
{
"Value": "Thoracic or lumbosacral neuritis or radiculitis, unspecified",
"DateTime": "2009-11-01T05:00:00.000Z",
"IsNegativeIndicator": false,
"Codes": [
{
"Code": "M54.16",
"CodeSystem": "2.16.840.1.113883.6.90",
"CodeSystemName": "ICD-10",
"Name": "Right lumbar radiculopathy"
}
],
"Comments": []
}
]
},
"CareTeams": [],
"ChiefComplaintText": "<paragraph>Dark stools.</paragraph>",
"DischargeDiagnosisText": null,
"DischargeDiagnosis": [],
"DischargeMedicationsText": null,
"DischargeMedications": [],
"EncountersText": "<table width=\"100%\"><thead><tr><th>Encounter</th><th>Performer</th><th>Location</th><th>Date</th></tr></thead><tbody><tr ID=\"Encounter1\"><td>Pnuemonia</td><td>Dr Henry Seven</td><td>Community Health and Hospitals</td><td>20120806</td></tr></tbody></table>",
"Encounters": [
{
"Identifiers": [
{
"ID": "2376492",
"IDType": "URMC Epic CSN"
},
{
"ID": "8237334",
"IDType": "1.35.829.5.238422.9.10"
}
],
"Type": {
"Code": "99222",
"CodeSystem": "2.16.840.1.113883.6.12",
"CodeSystemName": "CPT",
"Name": "InPatient Admission",
"AltCodes": []
},
"DateTime": "2012-08-06T04:00:00.000Z",
"EndDateTime": null,
"Providers": [
{
"NPI": null,
"ID": null,
"IDType": null,
"FirstName": null,
"LastName": null,
"Credentials": [],
"Address": {
"StreetAddress": null,
"City": null,
"State": null,
"ZIP": null,
"County": null,
"Country": null
},
"EmailAddresses": [],
"PhoneNumber": {
"Office": null
},
"Location": {
"Type": null,
"Facility": null,
"Department": null,
"Room": null
},
"Role": {
"Code": "59058001",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "General Physician",
"AltCodes": []
}
}
],
"Locations": [
{
"Identifiers": [],
"Telecom": [],
"Address": {
"StreetAddress": "1002 Healthcare Dr",
"City": "San Jose",
"State": "CA",
"Country": "USA",
"ZIP": "97266"
},
"Type": {
"Code": "1160-1",
"CodeSystem": "2.16.840.1.113883.6.259",
"CodeSystemName": "HealthcareServiceLocation",
"Name": "Urgent Care Center",
"AltCodes": []
},
"Name": "Community Health and Hospitals"
}
],
"Diagnosis": [
{
"Code": "233604007",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Pneumonia",
"AltCodes": []
}
],
"ReasonForVisit": [
{
"Code": "233604007",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Pneumonia",
"AltCodes": []
}
],
"DischargeDisposition": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
}
}
],
"FamilyHistoryText": "<paragraph>Father (deceased)</paragraph><table width=\"100%\"><thead><tr><th>Diagnosis</th><th>Age At Onset</th></tr></thead><tbody><tr><td>Myocardial Infarction (cause of death)</td><td>57</td></tr><tr><td>Diabetes</td><td>40</td></tr></tbody></table>",
"FamilyHistory": [
{
"Relation": {
"Code": "FTH",
"CodeSystem": "2.16.840.1.113883.5.111",
"CodeSystemName": "HL7 FamilyMember",
"Name": "Father",
"Demographics": {
"Sex": "Male",
"DOB": "1912-01-01"
},
"IsDeceased": true
},
"Problems": [
{
"Code": "22298006",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Myocardial infarction",
"AltCodes": [],
"Type": {
"Code": "55607006",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Problem"
},
"DateTime": null,
"AgeAtOnset": "57",
"IsCauseOfDeath": null
},
{
"Code": "46635009",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Diabetes mellitus type 1",
"AltCodes": [],
"Type": {
"Code": "64572001",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Condition"
},
"DateTime": "1994-01-01T05:00:00.000Z",
"AgeAtOnset": "40",
"IsCauseOfDeath": null
}
]
}
],
"FunctionalStatusText": "<table><thead><tr><th>Assessment</th><th>Date</th><th>Results</th><th>Comments</th></tr></thead><tbody><tr ID=\"FS_Narrative1\"><td ID=\"FS_Type\">Functional Status</td><td>August 15 2012, 5:32pm</td><td ID=\"FS_Finding1\">Dependence on walking stick</td><td></td></tr><tr ID=\"FS_Narrative2\"><td ID=\"FS_Type\">Functional Status</td><td>March 11 2013</td><td ID=\"FS_Finding1\">Independent with dressing</td><td></td></tr><tr ID=\"FS_Narrative3\"><td ID=\"FS_Type\">Transferring</td><td>March 11 2013</td><td ID=\"FS_Finding1\">Independent</td><td></td></tr><tr ID=\"FS_Narrative4\"><td ID=\"FS_Type\">Hearing</td><td>March 11 2013</td><td ID=\"FS_Finding1\">Impaired</td><td></td></tr></tbody></table>",
"FunctionalStatus": {
"Observations": [
{
"Code": "54522-8",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Functional Status",
"AltCodes": [],
"DateTime": "2012-08-15",
"CodedValue": {
"Code": "105504002",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Dependence on walking stick",
"AltCodes": []
},
"Value": "Dependence on walking stick",
"Units": null,
"ReferenceRange": {
"Low": null,
"High": null,
"Text": null
},
"Comments": []
},
{
"Code": "54522-8",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Functional Status",
"AltCodes": [],
"DateTime": "2013-03-11",
"CodedValue": {
"Code": "129035000",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Independent with dressing",
"AltCodes": []
},
"Value": "Independent with dressing",
"Units": null,
"ReferenceRange": {
"Low": null,
"High": null,
"Text": null
},
"Comments": []
},
{
"Code": "46482-6",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Transferring",
"AltCodes": [],
"DateTime": "2013-03-11",
"CodedValue": {
"Code": "371153006",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Independent",
"AltCodes": []
},
"Value": "Independent",
"Units": null,
"ReferenceRange": {
"Low": null,
"High": null,
"Text": null
},
"Comments": []
},
{
"Code": "47078008",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Hearing",
"AltCodes": [],
"DateTime": "2013-03-11",
"CodedValue": {
"Code": "260379002",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Impaired",
"AltCodes": []
},
"Value": "Impaired",
"Units": null,
"ReferenceRange": {
"Low": null,
"High": null,
"Text": null
},
"Comments": []
}
],
"Supplies": [
{
"Code": "14106009",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Cardiac Pacemaker",
"AltCodes": [],
"Status": "completed",
"DateTime": "2013-07-03"
}
]
},
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"HistoryOfPresentIllnessText": "<list><item><caption>Kelp, Lonnie Ray Sr., MD PHD - 10/21/2014 8:07 PM PST</caption><paragraph>Date: 10/21/2014<br/><br/>Pre-procedure diagnosis: L5 S1 Acute Lumbar Radiculopathy (Right)<br/><br/>Post-procedure diagnosis: Same<br/><br/>Procedure: 1) L5S1 Transforaminal Epidural Steroid injection(Right)<br/>2) Fluoroscopic Guidance for needle placement<br/><br/>Complications: None<br/><br/>CONSENT: Today's procedure, its potential benefits as well as its risks and potential side effects were reviewed. Discussed risks of the procedure include bleeding, infection, nerve irritation or damage, reactions to the medications, headache, failure of the pain to improve, and exacerbation of the pain were explained to the patient, who verbalized understanding and who wished to proceed. Informed consent was signed.<br/><br/>DESCRIPTION OF PROCEDURES: After written informed consent was obtained, the patient was taken to the fluoroscopy suite. Anatomical landmarks were identified by way of fluoroscopy in multiple views. Strict aseptic technique was utilized.<br/><br/>A 22-gauge 3-1/2-inch needle was then incrementally advanced using multiple fluoroscopic views from an oblique approach into the Right L5S1 lumbar intervertebral space. Both AP and lateral views were used to confirm final needle placement. After negative aspiration, Omniopaque 240 contrast was injected which delineated epidural without vascular flow and a normal epidurogram under fluoroscopy in the lateral and AP view. After negative aspiration was reconfirmed, a 1.0 mL of 0.25% Bupivicaine and 1mL of 40 mg/mL of Kenalog was slowly injected into the epidural space.<br/><br/>All needles were removed intact. Hemostasis was maintained. There were no complications. The area was cleaned and a Band-Aid placed as necessary. The patient tolerated the procedure well and all needles were removed intact. After a period of observation, the patient was noted to be hemodynamically stable and neurovascularly intact following the procedure as prior to the procedure, and was ultimately discharged to home with supervision in good condition. The patient was instructed to schedule an appointment in the office within 2 weeks.<br/>Lonnie Ray Kelp Sr., MD PHD<br/><br/></paragraph></item></list>",
"ImmunizationText": "<table width=\"100%\"><thead><tr><th>Vaccine</th><th>Date</th><th>Status</th></tr></thead><tbody><tr><td ID=\"immun2\">Influenza virus vaccine, IM</td><td>May 2012</td><td>Completed</td></tr><tr><td ID=\"immun4\">Tetanus and diphtheria toxoids, IM</td><td>Apr 2012</td><td>Completed</td></tr></tbody></table>",
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"InstructionsText": "Please carefully follow the subsequent instructions and patient education:<br/><br/><list><item>Floss</item><item>Brush teeth twice daily</item></list><br/><br/>Scarf tying instructions may be found online.",
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],
"ObjectiveText": "<list><item>Chest: clear to ausc. No rales, normal breath sounds</item><item>Heart: RR, PMI in normal location and no heave or evidence ofcardiomegaly,normal heart sounds, no murm or gallop</item></list>",
"PhysicalExamText": "All examinations performed within normal limits.<br/><br/>WNL<br/><br/>Nothing to report here.",
"PlanOfCareText": "<table width=\"100%\"><thead><tr><th>Planned Activity</th><th>Planned Date</th></tr></thead><tbody><tr><td>Consultation with Dr George Potomac for Asthma</td><td>20120820</td></tr><tr><td>Chest X-ray</td><td>20120826</td></tr><tr><td>Sputum Culture</td><td>20120820</td></tr></tbody></table>",
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]
},
"ProblemsText": "<list><item ID=\"problem1\">Pneumonia : Status - Resolved</item><item ID=\"problem2\">Asthma : Status - Active</item></list>",
"Problems": [
{
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}
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{
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],
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"Name": "Fake observation",
"AltCodes": [],
"DateTime": "2012-08-07",
"Status": "active",
"TargetSite": {
"Code": "302539009",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED-CT",
"Name": "Entire hand (body structure)",
"AltCodes": []
},
"Comments": []
}
],
"Procedures": [
{
"Code": "168731009",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED-CT",
"Name": "Chest X-Ray",
"AltCodes": [],
"DateTime": "2012-08-07",
"Status": "completed",
"TargetSite": {
"Code": "181608004",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED-CT",
"Name": "Entire chest wall (body structure)",
"AltCodes": []
},
"Comments": []
}
],
"Services": [
{
"Code": "123456",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED-CT",
"Name": "Fake action",
"AltCodes": [],
"DateTime": "2012-08-07",
"Status": "aborted",
"Comments": []
}
]
},
"ResolvedProblemsText": "<list><item ID=\"problem1\">Tobacco abuse : Status - Resolved</item></list>",
"ResolvedProblems": [
{
"StartDate": "2012-08-06T04:00:00.000Z",
"EndDate": "2012-08-06T04:00:00.000Z",
"Code": "110483000",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Tobacco abuse",
"AltCodes": [
{
"Code": "Z72.0",
"CodeSystem": "2.16.840.1.113883.6.90",
"CodeSystemName": "ICD-10-CM",
"Name": "Tobacco abuse"
},
{
"Code": "305.1",
"CodeSystem": "2.16.840.1.113883.6.103",
"CodeSystemName": "ICD-9-CM",
"Name": "Tobacco abuse"
},
{
"Code": "55885",
"CodeSystem": "2.16.840.1.113883.3.247.1.1",
"CodeSystemName": "Intelligent Medical Objects ProblemIT",
"Name": "Tobacco abuse"
}
],
"Category": {
"Code": "64572001",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Tobacco abuse",
"AltCodes": [
{
"Code": "75323-6",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Tobacco abuse"
}
]
},
"Status": {
"Code": "413322009",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Resolved"
},
"Comment": null,
"Comments": []
}
],
"ReasonForReferralText": "<table><colgroup><col width=\"16%\"/><col width=\"16%\"/><col width=\"18%\"/><col width=\"16%\"/><col width=\"16%\"/><col width=\"18%\"/></colgroup><thead><tr><th>Incoming Referral</th><th>Reason</th><th>Specialty</th><th>Diagnoses / Procedures</th><th>Referred By Contact</th><th>Referred To Contact</th></tr></thead><tbody><tr><td><paragraph>Consult, Test & Treat (Routine)</paragraph></td><td/><td>BA-Physical Medicine / Physical Medicine and Rehab</td><td><paragraph>Diagnoses</paragraph><paragraph>Radiculopathy, lumbar region</paragraph><paragraph>L5S1 TTRANSFORMINAL ESI</paragraph><paragraph>L5S1 TTRANSFORMINAL ESI</paragraph><paragraph>Procedures</paragraph><paragraph>PR INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVEL</paragraph><paragraph>INJECTION</paragraph></td><td><paragraph>Kelp, Lonnie Ray Sr., MD PHD</paragraph></td><td><paragraph>Kelp, Lonnie Ray Sr., MD PHD</paragraph></td></tr></tbody></table>",
"ReasonForVisitText": "<paragraph>Light stools.</paragraph>",
"ReasonForVisit": [
{
"Code": "27731006",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Soft stool",
"AltCodes": [],
"Category": {
"Code": "8661-1",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Chief Complaint",
"AltCodes": []
}
}
],
"ResultText": "<table><tbody><tr><td colspan=\"2\">LABORATORY INFORMATION</td></tr><tr><td colspan=\"2\">Chemistries and drug levels</td></tr><tr><td ID=\"result1\">HGB (M 13-18 g/dl; F 12-16 g/dl)</td><td>13.2</td></tr><tr><td ID=\"result2\">WBC (4.3-10.8 10+3/ul)</td><td>6.7</td></tr><tr><td ID=\"result3\">PLT (135-145 meq/l)</td><td>123 (L)</td></tr></tbody></table>",
"Results": [
{
"Code": "43789009",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "CBC WO DIFFERENTIAL",
"AltCodes": [],
"Encounter": {
"Identifiers": [],
"Type": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"DateTime": null,
"EndDateTime": null
},
"Status": "Final",
"Producer": {
"ID": "RL001",
"Name": "EHR Bridge Lab WI",
"IDType": null,
"Address": {
"StreetAddress": "111 W. Fairchild",
"City": "San Jose",
"State": "CA",
"ZIP": "53703",
"County": "Santa Clara",
"Country": "USA"
}
},
"Specimen": {
"CollectionDateTime": "2012-08-10T14:00:00.000Z",
"Identifiers": [
"1.2.840.113840.5^BL-201201-01"
],
"Source": {
"Code": "420135007",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Blood, whole"
},
"TargetSite": {
"Code": "LA",
"CodeSystem": "2.16.840.1.113883.18.81",
"CodeSystemName": "Body Site",
"Name": "Left Arm"
}
},
"Observations": [
{
"Code": "30313-1",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "HGB",
"AltCodes": [],
"Status": "Final",
"Interpretation": "Normal",
"DateTime": "2012-08-10T14:00:00.000Z",
"CodedValue": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"Value": "10.2",
"ValueType": "PhysicalQuantity",
"Units": "g/dl",
"ReferenceRange": {
"Low": null,
"High": null,
"Text": null
},
"Comments": []
},
{
"Code": "33765-9",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "WBC",
"AltCodes": [],
"Status": "Final",
"Interpretation": "Normal",
"DateTime": "2012-08-10T14:00:00.000Z",
"CodedValue": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"Value": "12.3",
"ValueType": "PhysicalQuantity",
"Units": "10+3/ul",
"ReferenceRange": {
"Low": null,
"High": null,
"Text": null
},
"Comments": []
},
{
"Code": "26515-7",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "PLT",
"AltCodes": [],
"Status": "Final",
"Interpretation": "Low",
"DateTime": "2012-08-10T14:00:00.000Z",
"CodedValue": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"Value": "123",
"ValueType": "PhysicalQuantity",
"Units": "10+3/ul",
"ReferenceRange": {
"Low": null,
"High": null,
"Text": null
},
"Comments": []
}
]
},
{
"Code": "624-7",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Sputum Culture",
"AltCodes": [],
"Encounter": {
"Identifiers": [],
"Type": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"DateTime": null,
"EndDateTime": null
},
"Status": "In Progress",
"Producer": {
"ID": "RL001",
"Name": "EHR Bridge Lab WI",
"IDType": null,
"Address": {
"StreetAddress": "111 W. Fairchild",
"City": "San Jose",
"State": "CA",
"ZIP": "53703",
"County": "Santa Clara",
"Country": "USA"
}
},
"Specimen": {
"CollectionDateTime": null,
"Identifiers": [],
"Source": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null
},
"TargetSite": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null
}
},
"Observations": [
{
"Code": "86243-3",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Color of Sputum",
"AltCodes": [],
"Status": "Final",
"Interpretation": null,
"DateTime": "2012-08-10T14:00:00.000Z",
"CodedValue": {
"Code": "54662009",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Green",
"AltCodes": []
},
"Value": "Green",
"ValueType": "Code",
"Units": null,
"ReferenceRange": {
"Low": null,
"High": null,
"Text": null
},
"Comments": []
}
]
}
],
"ReviewOfSystemsText": "<paragraph>Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. One episode of melena. No recent headaches. Positive for osteoarthritis in hips, knees and hands.</paragraph>",
"SocialHistoryText": "<table width=\"100%\"><thead><tr><th>Social History Element</th><th>Description</th><th>Effective Dates</th></tr></thead><tbody><tr><td ID=\"soc1\">smoking</td><td>Former Smoker (1 pack per day</td><td>20050501 to 20110227</td></tr><tr><td ID=\"soc2\">smoking</td><td>Current Everyday Smoker 2 packs per day</td><td>20110227 - today</td></tr></tbody></table>",
"SocialHistory": {
"Observations": [
{
"Code": "160573003",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Alcohol Consumption",
"AltCodes": [],
"Value": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"ValueText": "None",
"StartDate": "1990-05-01T04:00:00.000Z",
"EndDate": null,
"Comments": []
}
],
"Pregnancy": [],
"TobaccoUse": [
{
"Code": "8517006",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Former smoker",
"AltCodes": [],
"IsSmokingStatus": true,
"StartDate": "2015-06-03T09:35:00.000Z",
"EndDate": null,
"Comments": []
},
{
"Code": "65568007",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Cigarette smoker",
"AltCodes": [],
"IsSmokingStatus": false,
"StartDate": "2005-05-01",
"EndDate": "2008-09-01",
"Comments": []
}
]
},
"SubjectiveText": "<paragraph> Complaints of rectal bleeding, fatigue and a change in bowel patterns. Has several days of constipation alternating with diarrhea. </paragraph>",
"VitalSignsText": "<table width=\"100%\"><thead><tr><th align=\"right\">Date / Time: </th><th>Nov 1, 2011</th><th>August 6, 2012</th></tr></thead><tbody><tr><th align=\"left\">Height</th><td ID=\"vit1\">69 inches</td><td ID=\"vit2\">69 inches</td></tr><tr><th align=\"left\">Weight</th><td ID=\"vit3\">189 lbs</td><td ID=\"vit4\">194 lbs</td></tr><tr><th align=\"left\">Blood Pressure</th><td ID=\"vit5\">132/86 mmHg</td><td ID=\"vit6\">145/88 mmHg</td></tr></tbody></table>",
"VitalSigns": [
{
"DateTime": "1999-11-14T00:00:00.000Z",
"Observations": [
{
"Code": "8302-2",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Height",
"AltCodes": [],
"Status": "completed",
"Interpretation": "Normal",
"DateTime": "1999-11-14T00:00:00.000Z",
"Value": "177",
"Units": "cm",
"TargetSite": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"Comments": []
},
{
"Code": "3141-9",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Patient Body Weight - Measured",
"AltCodes": [],
"Status": "completed",
"Interpretation": "Normal",
"DateTime": "1999-11-14T00:00:00.000Z",
"Value": "86",
"Units": "kg",
"TargetSite": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"Comments": []
},
{
"Code": "8480-6",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Intravascular Systolic",
"AltCodes": [],
"Status": "completed",
"Interpretation": "Normal",
"DateTime": "1999-11-14T00:00:00.000Z",
"Value": "132",
"Units": "mm[Hg]",
"TargetSite": {
"Code": "368208006",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Left upper arm structure",
"AltCodes": []
},
"Comments": []
}
]
},
{
"DateTime": "2000-04-07T00:00:00.000Z",
"Observations": [
{
"Code": "8302-2",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Height",
"AltCodes": [],
"Status": "completed",
"Interpretation": "Normal",
"DateTime": "2000-04-07T00:00:00.000Z",
"Value": "177",
"Units": "cm",
"TargetSite": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"Comments": []
},
{
"Code": "3141-9",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Patient Body Weight - Measured",
"AltCodes": [],
"Status": "completed",
"Interpretation": "Normal",
"DateTime": "2000-04-07T00:00:00.000Z",
"Value": "88",
"Units": "kg",
"TargetSite": {
"Code": null,
"CodeSystem": null,
"CodeSystemName": null,
"Name": null,
"AltCodes": []
},
"Comments": []
},
{
"Code": "8480-6",
"CodeSystem": "2.16.840.1.113883.6.1",
"CodeSystemName": "LOINC",
"Name": "Intravascular Systolic",
"AltCodes": [],
"Status": "completed",
"Interpretation": "Normal",
"DateTime": "2000-04-07T00:00:00.000Z",
"Value": "145",
"Units": "mm[Hg]",
"TargetSite": {
"Code": "368208006",
"CodeSystem": "2.16.840.1.113883.6.96",
"CodeSystemName": "SNOMED CT",
"Name": "Left upper arm structure",
"AltCodes": []
},
"Comments": []
}
]
}
]
}