Communication #1 - Referral Note from the Primary Care Physician to the Optometrist (January 20, 2020, 11:00AM -0500)

Patient Legal: Clare M TESCA Date of Birth: February 14, 1952 (67yr) Gender: Female Patient-ID:  123456789 (SSN), 404.1 (1.3.6.1.4.1.115)
Encounter ID: 20200120103000 (2.16.840.1.113883.3.2820.10.1.3.10) , Date/Time: from January 20, 2020, 10:30AM -0500
Documentation Of Care provision, Patient referral (procedure), Date/Time: from January 20, 2020 to February 20, 2020, Performer: Joseph GOODDOC
Author Dr Joseph GOODDOC, Organization: Wood River Health Services, LLC, Authored On: January 20, 2020, 11:00AM -0500
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REASON FOR REFERRAL

Request Procedures Reason for Referral Referred By Contact Referred To Contact Specialty
Diabetic retinal eye exam Diabetic retinal eye exam (722161008) Diabetes with complaints of blurred vision and halos around lights at night.

Annual dilated diabetic eye exam.

Gooddoc, Joseph

800 Spring St.

Atlanta, GA 30308

Phone: 843-385-3448

Seemore, Yul

25 Fall St.

Atlanta, GA 30308

Phone: 843-555-9876

Optometry

ASSESSMENTS

No Information

HEALTH CONCERNS

Health Concerns
Type Health Concern Date Related Problem
Patient
Patient states father and uncle both had significant problems with vision from diabetes that started well before they were ready to retire. 01/10/2020 Type 2 diabetes mellitus without complications
She states she is having trouble controlling her glucose at home. She travels a lot for work and has more difficulty maintaining control when traveling. 01/20/2020 Type 2 diabetes mellitus without complications
Provider
Patient has fears regarding vision loss. 01/20/2020 Type 2 diabetes mellitus without complications
Patient is having difficulty balancing lifestyle changes with work. 01/20/2020 Type 2 diabetes mellitus without complications

GOALS

Goals were updated to better meet patient's lifestyle and encourage better compliance.

Problem Addressed Goal Goal Type Author
Diabetes Determine the cause of visual complaint. Patient stated Joseph Gooddoc, M.D.
Diabetes Get HbA1c below 8 within 6 months. Provider Joseph Gooddoc, M.D.

PLAN OF CARE

Date of Planned Services Type of Intervention Rationale Provider Location
(01/20/2020 - 02/20/2020 Diabetic retinal eye exam (procedure) Diabetes with complaints of blurred vision and halos around lights at night.

Annual dilated diabetic eye exam.

Seemore, Yul
25 Fall St.
Atlanta, GA 30308
843-555-9876

SOCIAL HISTORY

No Information

VITAL SIGNS

No Information

PROBLEM LIST

Problem Onset Date Resolved Date Status
Problem data included from 05/08/2006 to 01/20/2020 only
Type 2 diabetes mellitus without complications (111552007) 04/20/2014 active
Obesity, unspecified (414916001) 05/08/2006 active
Familial hypercholesterolemia (398036000) 04/20/2014 active
Essential (primary) hypertension (59621000) 07/28/2019 active

ALLERGIES AND ADVERSE REACTIONS

Time Substance Reaction Status
01/20/1998 egg Hives Active

MEDICATIONS

Active Medications
Name Code Instructions Start Date Stop Date Status
Crestor 5 mg 859426 (RxNorm) 1 tablet by mouth once a day for 90 2019-07-28 Active
metformin 1,000 mg 861004 (RxNorm) 1 tablet by mouth twice a day for 180 2014-04-20 Active
Invokana 100mg 50458-140-01 (NDC) 1 tablet by mouth once a day for 90 2019-07-28 Active
lisinopril 10 mg 314076 (RxNorm) 1 tablet by mouth once a day for 90 2019-07-28 Active

DIAGNOSTIC TESTS/LABORATORY RESULTS

Lab Results
Order Test Ref. Range Flags Result Units Obs. Date Performing Laboratory
Hemoglobin A1c
Hemoglobin A1c [Mass/volume] in Blood (41995-2) LESS THAN 7.0% (NORMAL) H 10.5 % 2020-01-14 09:33:00
Lipid Panel (24331-1)
Triglyceride [Mass/volume] in Blood (3043-7) LESS THAN 150 MG/DL (NORMAL) H 250 mg/dL 2020-01-14 09:33:00
Cholesterol in HDL [Mass/volume] in Serum or Plasma (2085-9) LESS THAN 50 MG/DL (NORMAL) 28 mg/dL 2020-01-14 09:33:00
Cholesterol in LDL [Mass/volume] in Serum or Plasma (2089-1) LESS THAN 100 MG/DL (NORMAL) H 180 mg/dL 2020-01-14 09:33:00
Cholesterol [Mass/volume] in Serum or Plasma (2093-3) LESS THAN 200 MG/DL (NORMAL) H 280 mg/dL 2020-01-14 09:33:00
Liver Panel (24324-6)
Albumin [Mass/volume] in Serum or Plasma (1751-7) 3.5-5.5 G/DL (NORMAL) H 6.0 g/dL 2020-01-14 09:33:00
Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma (1920-8) 9-50 U/L(NORMAL) H 60 U/L 2020-01-14 09:33:00
Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma (1742-6) 5-50 U/L(NORMAL) H 65 U/L 2020-01-14 09:33:00
Creatinine
Creatinine [Mass/volume] in Serum or Plasma (2160-0) LESS THAN 1.3 MG/DL H 1.5 mg/dL 2020-01-14 09:33:00

PATIENT CARE TEAMS

  • Long Term Care Team ( Active) (01/01/2005 - )
    Member Role on Team Status Date
    Dr. Joseph Gooddoc, MD (NPI: 2734441159 ) Primary Care Physician (Active) 2005 - current
    Maka Felgood Diabetic Educator (Active) 2014 - current
    Dr. Arthur Feetler, DPM (NPI: 8402871106) Podiatrist (Active) 2018 - current
    Dr. Donald Singletooth, DDS (NPI: 8477778822) Dentist (Active) 1990 - current

PAYERS

No Information
Document
ID b06a7d89-9ea1-4cd2-9a49-6eb768b17d41
Created On January 20, 2020, 11:00AM -0500
Custodian Wood River Health Services, LLC Contact Details Workplace: 800 Spring St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-2234
 
Patient Legal: Clare M TESCA Contact Details Home Primary: 3704 Irish Lane
Atlanta, GA 30301
US
Tel Home Primary: +1(843)-758-0515
Date of Birth February 14, 1952 (67yr) Gender Female
Race Black or African American Ethnicity Not Hispanic or Latino
Patient-IDs 123456789 (SSN)
404.1 (1.3.6.1.4.1.115)
Language Communication
en, Expressed spoken, Excellent, preferred: yes
Provider Organization
Wood River Health Services, LLC
ID 9999999999 (NPI), jgrue@directaddress.net (1.3.6.1.4.1.41179.2.1), 2.16.840.1.113883.1.111.12345
Contact Details (Organization) 800 Spring St.
Atlanta, GA 30308
US
Tel Workplace: +1-843-555-2234, Mail Workplace: jgrue@directaddress.net
 
Documentation Of - care provision Patient referral (procedure)from January 20, 2020 to February 20, 2020
Performer - Joseph GOODDOC Contact Details Workplace: 800 Spring St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-385-3448
Encounter
ID 20200120103000 (2.16.840.1.113883.3.2820.10.1.3.10)
Encounter Date from January 20, 2020, 10:30AM -0500
Encounter Location Wood River Health Services, LLC (Workplace: United States
Atlanta, GA 30308
800 Spring Street)
Responsible Party Legal: GOODDOC Joseph Contact Details Workplace: United States
Atlanta, GA 30308
800 Spring St.
 
Author Dr Joseph GOODDOC, Organization: Wood River Health Services, LLC Contact Details 800 Spring St.
Atlanta, Georgia 30308
US
Tel Workplace: +1-843-385-3448
Contact Details (Organization) Workplace: 800 Spring St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-2234
Information Recipient Yul SEEMORE Contact Details Workplace: 25 Fall St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9876