170.315 b9 Care Plan Ambulatory Sample 1 (v9) 1357 Amber Dr Beaverton OR 97006 Mckiney Karen Jones Mckiney Cathy Jones Neighborhood Physicians Practice 2472 Rocky place Beaverton OR 97006 Neighborhood Physicians Practice 2472 Rocky place Beaverton OR 97006 2472 Rocky place Beaverton OR 97006 Neighborhood Physicians Practice 2472 Rocky place Beaverton OR 97006 1357 Amber Dr Beaverton OR 97006 McKiney Matthew 1357 Amber Dr Beaverton OR 97006 Grazino Rick 2472 Rocky place Beaverton OR 97006 Davis Albert Dr 2472 Rocky place Beaverton OR 97006 Davis Tracy
Care Plan Summary
Patient is overweight as shown by the vital sign height and weight observations (6/22/2015 at 10:05 EST) (Active) Start: 6/22/2015
 • Goal: Keep weight under 95kg
  ◦ Intervention: Nutrition: dietary regime (regime/therapy) ; nutrition education (procedure)
  ◦ Outcome: a. Outcome Observation #1:i. Refers to Goal Observation for Weight; ii. Refers to the Intervention Act #1; iii. Progress Towards Goal of Weight – Goal Not Achieved as of 6/22/2015
Fever (6/22/2015 at 10:10 EST) (Active) Start: 6/22/2015
 • Goal: Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit
  ◦ Milestone: Get rid of intermittent fever that is occurring every few weeks.
  ◦ Intervention: Medications: Tylenol 500 mg
   ▪ Outcome: b. Outcome Observation #2: i. Refers to Goal Observation for Body Temperature; ii. Refers to Intervention Act #2 iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015
  ◦ Outcome: b. Outcome Observation #2: i. Refers to Goal Observation for Body Temperature; ii. Refers to Intervention Act #2 iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015
Increased body temperature as evidenced by Intermittent (recurrent) fever (Active) Start: 6/22/2015
 • Goal: Get rid of intermittent fever that is occurring every few weeks.
  ◦ Intervention: Medications: Ceftriaxone 100 MG/ML
Fatigue (Active) Start: 12/31/2006
 • Goal: Need to gain more energy to do regular activities.
  ◦ Intervention: Medications: Levothyroxine Sodium 1 mg
Hypertension: BP 145/88 (6/22/2015 at 10:08 EST) (Active) Start: 6/22/2015
Renal transplant rejection (Active) Start: 6/22/2015
 • Goal: Improve renal function
  ◦ Intervention: Medications: Aranesp 0.5 MG/ML
Health Concerns
Health Status
Chronic sickness 6/22/2015
Concerns
Patient is overweight as shown by the vital sign height and weight observations (6/22/2015 at 10:05 EST) Start: 6/22/2015
Status: Active
Provider Concern
Related To:
 • Overweight Onset: 12/31/2006
Status: Active
 • Weight 110 kg 22-Jun-2015 10:05
 • Height 177 cm 22-Jun-2015 10:05
Fever (6/22/2015 at 10:10 EST) Start: 6/22/2015
Status: Active
Provider Concern
Related Health Concern: Increased body temperature as evidenced by Intermittent (recurrent) fever
Related To:
 • Temperature 103 f 22-Jun-2015 10:10
Increased body temperature as evidenced by Intermittent (recurrent) fever Start: 6/22/2015
Status: Active
Provider Concern
Associated Health Concern: Fever (6/22/2015 at 10:10 EST)
Related To:
 • Intermittent (recurrent) fever Onset: 6/22/2015
Status: Active
 • Encounter Diagnosis: Fever Status: Active
Onset: 6/22/2015
Fatigue Start: 12/31/2006
Status: Active
Provider Concern
Related To:
 • Severe Hypothyroidism Onset: 12/31/2006
Status: Active
Hypertension: BP 145/88 (6/22/2015 at 10:08 EST) Start: 6/22/2015
Status: Active
Provider Concern
Related To:
 • Hypertension Onset: 10/5/2011
Status: Active
 • BP Systolic 145 mm[Hg] 22-Jun-2015 10:05
 • BP Diastolic 88 mm[Hg] 22-Jun-2015 10:05
Renal transplant rejection Start: 6/22/2015
Status: Active
Provider Concern
Related To:
 • Chronic rejection of renal transplant Onset: 12/31/2011
Status: Active
2472 Rocky place Beaverton OR 97006 Davis Albert Dr Active 2472 Rocky place Beaverton OR 97006 Davis Albert Dr Active 2472 Rocky place Beaverton OR 97006 Davis Albert Dr Active 2472 Rocky place Beaverton OR 97006 Davis Albert Dr Active 2472 Rocky place Beaverton OR 97006 Davis Albert Dr Active 2472 Rocky place Beaverton OR 97006 Davis Albert Dr Active
Goals
Get rid of intermittent fever that is occurring every few weeks. Goal Set: 6/22/2015 Patient and Provider Goal
Related To:
 • Increased body temperature as evidenced by Intermittent (recurrent) fever
Interventions
 • Ceftriaxone 100 MG/ML
Need to gain more energy to do regular activities. Goal Set: 6/22/2015 Patient and Provider Goal
Related To:
 • Fatigue
Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit Goal Set: 6/22/2015 Patient and Provider Goal
Related To:
 • Fever (6/22/2015 at 10:10 EST)
Interventions
 • Tylenol 500 mg
Milestones
 • Get rid of intermittent fever that is occurring every few weeks.
Keep weight under 95kg Goal Set: 6/22/2015 Provider Goal
Related To:
 • Patient is overweight as shown by the vital sign height and weight observations (6/22/2015 at 10:05 EST)
Interventions
 • dietary regime (regime/therapy)
 • nutrition education (procedure)
Improve renal function Goal Set: 6/22/2015 Patient and Provider Goal
Related To:
 • Renal transplant rejection
Interventions
 • Aranesp 0.5 MG/ML
Get rid of intermittent fever that is occurring every few weeks.
Interventions
Intervention For: Keep weight under 95kg
 • dietary regime (regime/therapy) Intent
 • nutrition education (procedure) Intent
Intervention For: Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit
 • Tylenol 500 mg ; oral as needed Start: 6/22/2015
End: 6/30/2015 		Status: Complete
Intervention For: Need to gain more energy to do regular activities.
 • Levothyroxine Sodium 1 mg ; oral daily Start: 6/23/2015
End: 6/30/2015 		Status: Complete
Intervention For: Get rid of intermittent fever that is occurring every few weeks.
 • Ceftriaxone 100 MG/ML ; two times daily Start: 6/22/2015
End: 7/22/2015 		Status: Complete
Intervention For: Improve renal function
 • Aranesp 0.5 MG/ML ; Injectable Once a week Start: 6/22/2015
End: 7/22/2015 		Status: Complete
Tylenol As Needed Synthroid ENOCEF Aranesp
Health Status Evaluations and Outcomes
a. Outcome Observation #1:i. Refers to Goal Observation for Weight; ii. Refers to the Intervention Act #1; iii. Progress Towards Goal of Weight – Goal Not Achieved as of 6/22/2015
Related Goal:
 • Keep weight under 95kg
Progress:
 • Goal not achieved 6/22/2015
b. Outcome Observation #2: i. Refers to Goal Observation for Body Temperature; ii. Refers to Intervention Act #2 iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015
Related Goal:
 • Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit
Interventions:
 • Tylenol 500 mg
Progress:
 • Goal achieved 6/22/2015
a. Outcome Observation #1:i. Refers to Goal Observation for Weight; ii. Refers to the Intervention Act #1; iii. Progress Towards Goal of Weight – Goal Not Achieved as of 6/22/2015 b. Outcome Observation #2: i. Refers to Goal Observation for Body Temperature; ii. Refers to Intervention Act #2 iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015