Skip to content
C-CDA R2.1 Patient Record: Sara Johnson 768 Johns Orchard Apt 26 West Springfield Massachusetts 01089 Sara Johnson RIVERBEND MEDICAL GROUP INC 1109 GRANBY RD CHICOPEE MA 01020-1568
Allergies There are no current allergies at the time of this document's creation.
Medications
Start Stop Description Code
1989-09-23T16:21:56-04:00 1989-10-23T16:21:56-04:00 Acetaminophen 160 MG Oral Tablet RxNorm 282464
1995-12-26T15:21:56-05:00 Clonazepam [Klonopin] RxNorm 1153378
1996-04-16T16:21:56-04:00 1996-08-20T16:21:56-04:00 Carbamazepine[Tegretol] RxNorm 308971
1997-01-29T15:21:56-05:00 Diazepam [Valium] RxNorm 563026
Acetaminophen 160 MG Oral Tablet Clonazepam [Klonopin] Carbamazepine[Tegretol] Diazepam [Valium]
Diagnostic Results
Start Stop Description Code
1988-12-14T15:21:56-05:00 Complete blood count (hemogram) panel - Blood by Automated count LOINC 58410-2
1994-01-12T15:21:56-05:00 Complete blood count (hemogram) panel - Blood by Automated count LOINC 58410-2
1997-08-20T16:21:56-04:00 U.S. standard certificate of death - 2003 revision LOINC 69409-1
{entry.value}
Problems
Start Stop Description Code
1989-09-23T16:21:56-04:00 1989-10-23T16:21:56-04:00 An initial facet injection (intra-articular and medial branch block) from C2-3 to L5-S1 is considered medically necessary for the diagnosis of facet pain in persons with severe chronic neck and back pain when the following criteria are met: Member has symptoms suggestive of facet joint syndrome (symptoms of facet joint syndrome include absence of radiculopathy, pain that is aggravated by extension, rotation or lateral bending of the spine and is not typically associated with any neurological deficits); and Facet mediated pain is confirmed by provocative testing on physical examination (to confirm that pain is exacerbated by extension and rotation); and Imaging studies suggest no other obvious cause of pain (such as fracture, tumor, infection, or significant extraspinal lesion); and Pain limits daily activities; and Pain has lasted more than 3 months; and Pain has persisted despite six or more weeks of conservative treatment (including, systemic medications, and/or physical therapy); and Radiofrequency facet neurolysis is being considered. SNOMED-CT 359817006
1991-10-18T16:21:56-04:00 1991-11-08T15:21:56-05:00 Injection of no more than three (3) facet joint levels are considered medically necessary during the same session/procedure. These may be performed bilaterally during the same session for a total of up to six injections SNOMED-CT 444814009
1995-12-26T15:21:56-05:00 A second diagnostic facet injection (intraarticular and medial branch block) is considered medically necessary to confirm the validity of the clinical response to the initial facet injection when it is administered at the same level as the initial facet injection, and where the initial facet injection produced a positive response (i.e., resulted in an 80% relief of facet mediated pain for at least the expected minimum duration of the effect of the local anesthetic). If the initial injection did not produce a positive response, a second diagnostic injection is considered not medically necessary SNOMED-CT 128613002
1995-12-26T15:21:56-05:00 Conservative treatment such as bed rest, exercises, heating or cooling modalities, massage, and pharmacotherapies such as non-steroidal anti-inflammatory drugs (NSAIDS), muscle relaxants, non-narcotic analgesics, should have been tried and failed SNOMED-CT 703151001
Surgeries
Start Stop Description Code
1989-09-23T16:21:56-04:00 1989-09-23T16:51:56-04:00 Facet joint injections SNOMED-CT 268425006
1989-09-23T16:21:56-04:00 1989-09-23T17:21:56-04:00 Trigger point injections SNOMED-CT 305428000
1992-01-01T15:21:56-05:00 1992-01-01T15:36:56-05:00 Medication Reconciliation (procedure) SNOMED-CT 430193006
1993-01-06T15:21:56-05:00 1993-01-06T15:36:56-05:00 Medication Reconciliation (procedure) SNOMED-CT 430193006
1995-12-26T15:21:56-05:00 1995-12-26T17:49:56-05:00 Seizure Count Cerebral Cortex Electroencephalogram (EEG) SNOMED-CT 54550000
1996-04-16T16:21:56-04:00 1996-04-16T17:43:56-04:00 Seizure Count Cerebral Cortex Electroencephalogram (EEG) SNOMED-CT 54550000
Encounters
Start Stop Description Code
1987-12-09T15:21:56-05:00 1987-12-09T15:36:56-05:00 Well child visit (procedure) SNOMED-CT 410620009
1988-12-14T15:21:56-05:00 1988-12-14T15:36:56-05:00 Well child visit (procedure) SNOMED-CT 410620009
1989-09-23T16:21:56-04:00 1989-09-23T18:51:56-04:00 Emergency room admission (procedure) SNOMED-CT 50849002
1989-10-23T16:21:56-04:00 1989-10-23T16:36:56-04:00 Encounter for 'check-up' SNOMED-CT 185349003
1989-12-20T15:21:56-05:00 1989-12-20T15:36:56-05:00 Well child visit (procedure) SNOMED-CT 410620009
1990-12-26T15:21:56-05:00 1990-12-26T15:36:56-05:00 Well child visit (procedure) SNOMED-CT 410620009
1991-10-18T16:21:56-04:00 1991-10-18T16:36:56-04:00 Encounter for symptom SNOMED-CT 185345009
1992-01-01T15:21:56-05:00 1992-01-01T15:51:56-05:00 Well child visit (procedure) SNOMED-CT 410620009
1993-01-06T15:21:56-05:00 1993-01-06T15:51:56-05:00 Well child visit (procedure) SNOMED-CT 410620009
1994-01-12T15:21:56-05:00 1994-01-12T15:36:56-05:00 Well child visit (procedure) SNOMED-CT 410620009
1995-01-18T15:21:56-05:00 1995-01-18T15:36:56-05:00 Well child visit (procedure) SNOMED-CT 410620009
1995-12-26T15:21:56-05:00 1995-12-26T18:49:56-05:00 Emergency Room Admission SNOMED-CT 50849002
1996-01-24T15:21:56-05:00 1996-01-24T15:36:56-05:00 Well child visit (procedure) SNOMED-CT 410620009
1996-04-16T16:21:56-04:00 1996-04-16T18:43:56-04:00 Emergency Room Admission SNOMED-CT 50849002
1997-01-29T15:21:56-05:00 1997-01-29T15:36:56-05:00 Well child visit (procedure) SNOMED-CT 410620009
1997-08-20T16:21:56-04:00 1997-08-20T16:36:56-04:00 Death Certification SNOMED-CT 308646001
Vital Signs
Start Stop Description Code Value
1987-12-09T15:21:56-05:00 Body Height LOINC 8302-2 101.55598942717468 cm
1987-12-09T15:21:56-05:00 Pain severity - 0-10 verbal numeric rating [Score] - Reported LOINC 72514-3 1.4538433289561556 {score}
1987-12-09T15:21:56-05:00 Body Weight LOINC 29463-7 16.19641331162453 kg
1987-12-09T15:21:56-05:00 Body Mass Index LOINC 39156-5 15.70390890882543 kg/m2
1987-12-09T15:21:56-05:00 Body mass index (BMI) [Percentile] Per age and gender LOINC 59576-9 65.5663952050745 %
1987-12-09T15:21:56-05:00 Blood Pressure LOINC 55284-4 Diastolic Blood Pressure 82.08847717078976 mm[Hg] Systolic Blood Pressure 132.68425913534497 mm[Hg]
1987-12-09T15:21:56-05:00 Tobacco smoking status NHIS LOINC 72166-2 SNOMED-CT 266919005 Never smoker
1988-12-14T15:21:56-05:00 Body Height LOINC 8302-2 108.159508881863 cm
1988-12-14T15:21:56-05:00 Pain severity - 0-10 verbal numeric rating [Score] - Reported LOINC 72514-3 3.444078106706093 {score}
1988-12-14T15:21:56-05:00 Body Weight LOINC 29463-7 18.189745480940918 kg
1988-12-14T15:21:56-05:00 Body Mass Index LOINC 39156-5 15.548811874389013 kg/m2
1988-12-14T15:21:56-05:00 Body mass index (BMI) [Percentile] Per age and gender LOINC 59576-9 59.19356806483182 %
1988-12-14T15:21:56-05:00 Blood Pressure LOINC 55284-4 Diastolic Blood Pressure 84.64092020237942 mm[Hg] Systolic Blood Pressure 113.35398543300268 mm[Hg]
1988-12-14T15:21:56-05:00 Leukocytes [#/volume] in Blood by Automated count LOINC 6690-2 7.362416792741564 10*3/uL
1988-12-14T15:21:56-05:00 Erythrocytes [#/volume] in Blood by Automated count LOINC 789-8 4.347154813824572 10*6/uL
1988-12-14T15:21:56-05:00 Hemoglobin [Mass/volume] in Blood LOINC 718-7 12.468484793601563 g/dL
1988-12-14T15:21:56-05:00 Hematocrit [Volume Fraction] of Blood by Automated count LOINC 4544-3 39.98025144651147 %
1988-12-14T15:21:56-05:00 MCV [Entitic volume] by Automated count LOINC 787-2 80.99170356723494 fL
1988-12-14T15:21:56-05:00 MCH [Entitic mass] by Automated count LOINC 785-6 30.820749545818135 pg
1988-12-14T15:21:56-05:00 MCHC [Mass/volume] by Automated count LOINC 786-4 34.83593243049633 g/dL
1988-12-14T15:21:56-05:00 Erythrocyte distribution width [Entitic volume] by Automated count LOINC 21000-5 45.64492250727226 fL
1988-12-14T15:21:56-05:00 Platelets [#/volume] in Blood by Automated count LOINC 777-3 345.4267181645224 10*3/uL
1988-12-14T15:21:56-05:00 Platelet distribution width [Entitic volume] in Blood by Automated count LOINC 32207-3 371.27927941035125 fL
1988-12-14T15:21:56-05:00 Platelet mean volume [Entitic volume] in Blood by Automated count LOINC 32623-1 11.861186935189773 fL
1988-12-14T15:21:56-05:00 Tobacco smoking status NHIS LOINC 72166-2 SNOMED-CT 266919005 Never smoker
1989-12-20T15:21:56-05:00 Body Height LOINC 8302-2 114.51429345393846 cm
1989-12-20T15:21:56-05:00 Pain severity - 0-10 verbal numeric rating [Score] - Reported LOINC 72514-3 0.0953073740540558 {score}
1989-12-20T15:21:56-05:00 Body Weight LOINC 29463-7 20.321619072847106 kg
1989-12-20T15:21:56-05:00 Body Mass Index LOINC 39156-5 15.496688757732349 kg/m2
1989-12-20T15:21:56-05:00 Body mass index (BMI) [Percentile] Per age and gender LOINC 59576-9 51.682939934373515 %
1989-12-20T15:21:56-05:00 Blood Pressure LOINC 55284-4 Diastolic Blood Pressure 71.65797406649364 mm[Hg] Systolic Blood Pressure 125.25823836217977 mm[Hg]
1989-12-20T15:21:56-05:00 Tobacco smoking status NHIS LOINC 72166-2 SNOMED-CT 266919005 Never smoker
1990-12-26T15:21:56-05:00 Body Height LOINC 8302-2 120.20740818107828 cm
1990-12-26T15:21:56-05:00 Pain severity - 0-10 verbal numeric rating [Score] - Reported LOINC 72514-3 0.376448564602974 {score}
1990-12-26T15:21:56-05:00 Body Weight LOINC 29463-7 22.68465606105073 kg
1990-12-26T15:21:56-05:00 Body Mass Index LOINC 39156-5 15.698918408689861 kg/m2
1990-12-26T15:21:56-05:00 Body mass index (BMI) [Percentile] Per age and gender LOINC 59576-9 47.96782515477607 %
1990-12-26T15:21:56-05:00 Blood Pressure LOINC 55284-4 Diastolic Blood Pressure 73.71873868292829 mm[Hg] Systolic Blood Pressure 122.18754092707857 mm[Hg]
1990-12-26T15:21:56-05:00 Tobacco smoking status NHIS LOINC 72166-2 SNOMED-CT 266919005 Never smoker
1992-01-01T15:21:56-05:00 Body Height LOINC 8302-2 125.4704473919327 cm
1992-01-01T15:21:56-05:00 Pain severity - 0-10 verbal numeric rating [Score] - Reported LOINC 72514-3 2.2589871743256116 {score}
1992-01-01T15:21:56-05:00 Body Weight LOINC 29463-7 25.660526701663926 kg
1992-01-01T15:21:56-05:00 Body Mass Index LOINC 39156-5 16.299814923168086 kg/m2
1992-01-01T15:21:56-05:00 Body mass index (BMI) [Percentile] Per age and gender LOINC 59576-9 49.87993334120209 %
1992-01-01T15:21:56-05:00 Blood Pressure LOINC 55284-4 Diastolic Blood Pressure 85.98991354203812 mm[Hg] Systolic Blood Pressure 108.13033377882891 mm[Hg]
1992-01-01T15:21:56-05:00 Tobacco smoking status NHIS LOINC 72166-2 SNOMED-CT 266919005 Never smoker
1993-01-06T15:21:56-05:00 Body Height LOINC 8302-2 129.90886620820288 cm
1993-01-06T15:21:56-05:00 Pain severity - 0-10 verbal numeric rating [Score] - Reported LOINC 72514-3 2.5647175002767097 {score}
1993-01-06T15:21:56-05:00 Body Weight LOINC 29463-7 28.880975347284227 kg
1993-01-06T15:21:56-05:00 Body Mass Index LOINC 39156-5 17.11331998775204 kg/m2
1993-01-06T15:21:56-05:00 Body mass index (BMI) [Percentile] Per age and gender LOINC 59576-9 54.224755341425855 %
1993-01-06T15:21:56-05:00 Blood Pressure LOINC 55284-4 Diastolic Blood Pressure 85.31443018480512 mm[Hg] Systolic Blood Pressure 132.70215000343555 mm[Hg]
1993-01-06T15:21:56-05:00 Tobacco smoking status NHIS LOINC 72166-2 SNOMED-CT 266919005 Never smoker
1994-01-12T15:21:56-05:00 Body Height LOINC 8302-2 135.14708206033657 cm
1994-01-12T15:21:56-05:00 Pain severity - 0-10 verbal numeric rating [Score] - Reported LOINC 72514-3 2.945592655467845 {score}
1994-01-12T15:21:56-05:00 Body Weight LOINC 29463-7 32.514543388990994 kg
1994-01-12T15:21:56-05:00 Body Mass Index LOINC 39156-5 17.801816201569473 kg/m2
1994-01-12T15:21:56-05:00 Body mass index (BMI) [Percentile] Per age and gender LOINC 59576-9 55.11846959852642 %
1994-01-12T15:21:56-05:00 Blood Pressure LOINC 55284-4 Diastolic Blood Pressure 84.37438604730526 mm[Hg] Systolic Blood Pressure 130.24562137828207 mm[Hg]
1994-01-12T15:21:56-05:00 Leukocytes [#/volume] in Blood by Automated count LOINC 6690-2 9.408994049150923 10*3/uL
1994-01-12T15:21:56-05:00 Erythrocytes [#/volume] in Blood by Automated count LOINC 789-8 5.157055729504211 10*6/uL
1994-01-12T15:21:56-05:00 Hemoglobin [Mass/volume] in Blood LOINC 718-7 14.224201844597637 g/dL
1994-01-12T15:21:56-05:00 Hematocrit [Volume Fraction] of Blood by Automated count LOINC 4544-3 45.29959579539084 %
1994-01-12T15:21:56-05:00 MCV [Entitic volume] by Automated count LOINC 787-2 90.50710063840468 fL
1994-01-12T15:21:56-05:00 MCH [Entitic mass] by Automated count LOINC 785-6 27.705330543697166 pg
1994-01-12T15:21:56-05:00 MCHC [Mass/volume] by Automated count LOINC 786-4 35.823075491606744 g/dL
1994-01-12T15:21:56-05:00 Erythrocyte distribution width [Entitic volume] by Automated count LOINC 21000-5 43.78654018445962 fL
1994-01-12T15:21:56-05:00 Platelets [#/volume] in Blood by Automated count LOINC 777-3 427.2223711443111 10*3/uL
1994-01-12T15:21:56-05:00 Platelet distribution width [Entitic volume] in Blood by Automated count LOINC 32207-3 392.88206250802887 fL
1994-01-12T15:21:56-05:00 Platelet mean volume [Entitic volume] in Blood by Automated count LOINC 32623-1 12.050836991799503 fL
1994-01-12T15:21:56-05:00 Tobacco smoking status NHIS LOINC 72166-2 SNOMED-CT 266919005 Never smoker
1995-01-18T15:21:56-05:00 Body Height LOINC 8302-2 142.11529344380534 cm
1995-01-18T15:21:56-05:00 Pain severity - 0-10 verbal numeric rating [Score] - Reported LOINC 72514-3 2.707393188789343 {score}
1995-01-18T15:21:56-05:00 Body Weight LOINC 29463-7 36.37210231443362 kg
1995-01-18T15:21:56-05:00 Body Mass Index LOINC 39156-5 18.008882802148737 kg/m2
1995-01-18T15:21:56-05:00 Body mass index (BMI) [Percentile] Per age and gender LOINC 59576-9 48.61408009412957 %
1995-01-18T15:21:56-05:00 Blood Pressure LOINC 55284-4 Diastolic Blood Pressure 85.23700090477698 mm[Hg] Systolic Blood Pressure 115.87319056383934 mm[Hg]
1995-01-18T15:21:56-05:00 Tobacco smoking status NHIS LOINC 72166-2 SNOMED-CT 266919005 Never smoker
1996-01-24T15:21:56-05:00 Body Height LOINC 8302-2 148.58291239824007 cm
1996-01-24T15:21:56-05:00 Pain severity - 0-10 verbal numeric rating [Score] - Reported LOINC 72514-3 1.2775810215773076 {score}
1996-01-24T15:21:56-05:00 Body Weight LOINC 29463-7 40.15362920670418 kg
1996-01-24T15:21:56-05:00 Body Mass Index LOINC 39156-5 18.188089000639284 kg/m2
1996-01-24T15:21:56-05:00 Body mass index (BMI) [Percentile] Per age and gender LOINC 59576-9 41.959549368371746 %
1996-01-24T15:21:56-05:00 Blood Pressure LOINC 55284-4 Diastolic Blood Pressure 87.10472369940598 mm[Hg] Systolic Blood Pressure 110.08202125566083 mm[Hg]
1996-01-24T15:21:56-05:00 Tobacco smoking status NHIS LOINC 72166-2 SNOMED-CT 266919005 Never smoker
1997-01-29T15:21:56-05:00 Body Height LOINC 8302-2 152.37401320244902 cm
1997-01-29T15:21:56-05:00 Pain severity - 0-10 verbal numeric rating [Score] - Reported LOINC 72514-3 0.1499472466370393 {score}
1997-01-29T15:21:56-05:00 Body Weight LOINC 29463-7 43.78558923486922 kg
1997-01-29T15:21:56-05:00 Body Mass Index LOINC 39156-5 18.85859727888072 kg/m2
1997-01-29T15:21:56-05:00 Body mass index (BMI) [Percentile] Per age and gender LOINC 59576-9 42.33305080715585 %
1997-01-29T15:21:56-05:00 Blood Pressure LOINC 55284-4 Diastolic Blood Pressure 80.67617116856186 mm[Hg] Systolic Blood Pressure 120.99065595661092 mm[Hg]
1997-01-29T15:21:56-05:00 Tobacco smoking status NHIS LOINC 72166-2 SNOMED-CT 266919005 Never smoker
1997-08-20T16:21:56-04:00 Cause of Death [US Standard Certificate of Death] LOINC 69453-9 SNOMED-CT 95281009 Sudden Cardiac Death
SNOMED-CT 266919005 Never smoker SNOMED-CT 266919005 Never smoker SNOMED-CT 266919005 Never smoker SNOMED-CT 266919005 Never smoker SNOMED-CT 266919005 Never smoker SNOMED-CT 266919005 Never smoker SNOMED-CT 266919005 Never smoker SNOMED-CT 266919005 Never smoker SNOMED-CT 266919005 Never smoker SNOMED-CT 266919005 Never smoker SNOMED-CT 95281009 Sudden Cardiac Death
Immunizations
Start Stop Description Code
1987-12-09T15:21:56-05:00 varicella http://hl7.org/fhir/sid/cvx 21
1987-12-09T15:21:56-05:00 IPV http://hl7.org/fhir/sid/cvx 10
1987-12-09T15:21:56-05:00 Influenza, seasonal, injectable, preservative free http://hl7.org/fhir/sid/cvx 140
1987-12-09T15:21:56-05:00 MMR http://hl7.org/fhir/sid/cvx 03
1988-12-14T15:21:56-05:00 Influenza, seasonal, injectable, preservative free http://hl7.org/fhir/sid/cvx 140
1989-12-20T15:21:56-05:00 Influenza, seasonal, injectable, preservative free http://hl7.org/fhir/sid/cvx 140
1990-12-26T15:21:56-05:00 Influenza, seasonal, injectable, preservative free http://hl7.org/fhir/sid/cvx 140
1992-01-01T15:21:56-05:00 Influenza, seasonal, injectable, preservative free http://hl7.org/fhir/sid/cvx 140
1993-01-06T15:21:56-05:00 Influenza, seasonal, injectable, preservative free http://hl7.org/fhir/sid/cvx 140
1994-01-12T15:21:56-05:00 Influenza, seasonal, injectable, preservative free http://hl7.org/fhir/sid/cvx 140
1995-01-18T15:21:56-05:00 Influenza, seasonal, injectable, preservative free http://hl7.org/fhir/sid/cvx 140
1996-01-24T15:21:56-05:00 Influenza, seasonal, injectable, preservative free http://hl7.org/fhir/sid/cvx 140
1997-01-29T15:21:56-05:00 Influenza, seasonal, injectable, preservative free http://hl7.org/fhir/sid/cvx 140
varicella IPV Influenza, seasonal, injectable, preservative free MMR Influenza, seasonal, injectable, preservative free Influenza, seasonal, injectable, preservative free Influenza, seasonal, injectable, preservative free Influenza, seasonal, injectable, preservative free Influenza, seasonal, injectable, preservative free Influenza, seasonal, injectable, preservative free Influenza, seasonal, injectable, preservative free Influenza, seasonal, injectable, preservative free Influenza, seasonal, injectable, preservative free
Plan of Care
Start Stop Description Code
1989-09-23T16:21:56-04:00 1989-10-23T16:21:56-04:00 Fracture care SNOMED-CT 385691007
Imaging Studies
Social History There is no current social history at the time of this document's creation.