2
-X POST https://api.redoxengine.com/endpoint \
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-H "Content-Type: application/json" \
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-H "Authorization: Bearer $API_TOKEN" \
7
"DataModel": "Clinical Summary",
8
"EventType": "VisitPush",
12
"ID": "{{DATA-ON-DEMAND-REPOSITORY-ID}}"
17
"DirectAddressFrom": null,
18
"DirectAddressTo": null,
25
"LastName": "Granite",
30
"StreetAddress": "123 Main St.",
39
"Office": "+16085551234"
44
"ID": "{{REDOX-PARENT-OID}}^67890",
46
"Title": "Community Health and Hospitals: Annual Physical",
47
"DateTime": "2012-09-12T00:00:00.000Z",
48
"Type": "Progress Note",
51
"CodeSystem": "2.16.840.1.113883.6.1",
52
"CodeSystemName": "LOINC",
53
"Name": "Progress Note"
57
"Type": "Outpatient Clinic",
58
"Facility": "RHS Vista Oaks Clinic",
59
"Department": "Vista Oaks Clinic",
62
"StartDateTime": "2020-11-12T00:18:30.592Z",
63
"EndDateTime": "2020-11-12T00:18:30.592Z",
64
"Reason": "Annual Physical",
65
"VisitNumber": "30311442"
75
"FirstName": "Timothy",
83
"MaritalStatus": "Married",
85
"DeathDateTime": null,
87
"Home": "+18088675301",
93
"StreetAddress": "4762 Hickory Street",
104
"AdvanceDirectivesText": "
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Directive Description Verification Supporting Document(s)
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Resuscitation status Do not resuscitate Dr. Robert Dolin, Nov 07, 1999 Advance directive
108
"AdvanceDirectives": [
112
"CodeSystem": "2.16.840.1.113883.6.96",
113
"CodeSystemName": "SNOMED CT",
114
"Name": "Resuscitation",
118
"CodeSystem": "2.16.840.1.113883.6.96",
119
"CodeSystemName": "SNOMED CT",
120
"Name": "Do not resuscitate",
122
"StartDate": "2011-02-13T05:00:00.000Z",
124
"ExternalReference": "AdvanceDirective.b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3.pdf",
127
"FirstName": "Robert",
129
"Credentials": "Dr.",
135
"FirstName": "Robert",
137
"Credentials": "Dr.",
145
Substance Reaction Severity Status
146
Penicillin G benzathine Hives Moderate to severe Inactive
147
Codeine Shortness of Breath Moderate Active
148
Aspirin Hives Mild to moderate Active
154
"AssessmentText": "Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy.Acute on chronic anemia secondary to #1.Azotemia, acute renal failure with volume loss secondary to #1.Hyperkalemia secondary to #3 and on ACE and K+ supplement.Other chronic diagnoses as noted above, currently stable.Also, this person has back problems.",
158
"Value": "Displacement of lumbar intervertebral disc without myelopathy",
159
"DateTime": "2009-11-01T05:00:00.000Z",
160
"IsNegativeIndicator": false,
164
"CodeSystem": "2.16.840.1.113883.6.96",
165
"CodeSystemName": "SNOMED-CT",
166
"Name": "Herniated lumbar intervertebral disc"
173
"Value": "Thoracic or lumbosacral neuritis or radiculitis, unspecified",
174
"DateTime": "2009-11-01T05:00:00.000Z",
175
"IsNegativeIndicator": false,
179
"CodeSystem": "2.16.840.1.113883.6.90",
180
"CodeSystemName": "ICD-10",
181
"Name": "Right lumbar radiculopathy"
187
"ChiefComplaintText": "Dark stools.",
189
Encounter Performer Location Date
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Pnuemonia Dr Henry Seven Community Health and Hospitals 20120806
197
"IDType": "URMC Epic CSN"
202
"CodeSystem": "2.16.840.1.113883.6.12",
203
"CodeSystemName": "CPT",
204
"Name": "InPatient Admission",
207
"DateTime": "2012-08-06T04:00:00.000Z",
214
"CodeSystem": "2.16.840.1.113883.6.96",
215
"CodeSystemName": "SNOMED CT",
223
"CodeSystem": "2.16.840.1.113883.6.96",
224
"CodeSystemName": "SNOMED CT",
231
"FamilyHistoryText": "Father (deceased)
232
Diagnosis Age At Onset
233
Myocardial Infarction (cause of death) 57
236
"FamilyHistory": [ ...
238
"HistoryOfPresentIllnessText": "Kelp, Lonnie Ray Sr., MD PHD - 10/21/2014 8:07 PM PSTDate: 10/21/2014
240
Pre-procedure diagnosis: L5 S1 Acute Lumbar Radiculopathy (Right)
242
Post-procedure diagnosis: Same
244
Procedure: 1) L5S1 Transforaminal Epidural Steroid injection(Right)
245
2) Fluoroscopic Guidance for needle placement
249
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.
251
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.
253
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.
255
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.
256
Lonnie Ray Kelp Sr., MD PHD
259
"ImmunizationText": "
261
Influenza virus vaccine, IM May 2012 Completed
262
Tetanus and diphtheria toxoids, IM Apr 2012 Completed
264
"Immunizations": [ ...
266
"InstructionsText": "Please carefully follow the subsequent instructions and patient education:
268
FlossBrush teeth twice daily
270
Scarf tying instructions may be found online.",
271
"InsurancesText": null,
278
"InterventionsText": "Patient practiced use of novel prosthesis including movements formerly neglected including distal extension and retroflexive hyperextension.",
279
"MedicalEquipmentText": "
280
Supply/Device Date Supplied
281
Automatic implantable cardioverter/defibrillator Nov 1999
282
Total hip replacement prosthesis 1998
285
"MedicalEquipment": [ ...
288
Medication Directions Start Date Status Indications Fill Instructions
289
Albuterol 0.09 MG/ACTUAT inhalant solution 0.09 MG/ACTUAT inhalant solution, 2 puffs once 20120806 Active Pneumonia (233604007 SNOMED CT) Generic Substitition Allowed
293
"MedicationsAdministeredText": "
294
Medication Start Date Status
295
Albuterol 0.09 MG/ACTUAT inhalant solution 0.09 MG/ACTUAT inhalant solution, 2 puffs once 20120806 Active
297
"MedicationsAdministered": [ ...
299
"ObjectiveText": "Chest: clear to ausc. No rales, normal breath soundsHeart: RR, PMI in normal location and no heave or evidence ofcardiomegaly,normal heart sounds, no murm or gallop",
300
"PhysicalExamText": "All examinations performed within normal limits.
304
Nothing to report here.",
306
Planned Activity Planned Date
307
Consultation with Dr George Potomac for Asthma 20120820
309
Sputum Culture 20120820
313
"ProblemsText": "Pneumonia : Status - ResolvedAsthma : Status - Active",
322
"ReasonForReferralText": "
323
Incoming Referral Reason Specialty Diagnoses / Procedures Referred By Contact Referred To Contact
324
Consult, Test & Treat (Routine) BA-Physical Medicine / Physical Medicine and Rehab DiagnosesRadiculopathy, lumbar regionL5S1 TTRANSFORMINAL ESIL5S1 TTRANSFORMINAL ESIProceduresPR INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVELINJECTION Kelp, Lonnie Ray Sr., MD PHD Kelp, Lonnie Ray Sr., MD PHD
326
"ReasonForVisitText": "Light stools.",
328
LABORATORY INFORMATION
329
Chemistries and drug levels
330
HGB (M 13-18 g/dl; F 12-16 g/dl) 13.2
331
WBC (4.3-10.8 10+3/ul) 6.7
332
PLT (135-145 meq/l) 123 (L)
336
"ReviewOfSystemsText": "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.",
337
"SocialHistoryText": "
338
Social History Element Description Effective Dates
339
smoking Former Smoker (1 pack per day 20050501 to 20110227
340
smoking Current Everyday Smoker 2 packs per day 20110227 - today
342
"SocialHistory": { ...
344
"SubjectiveText": " Complaints of rectal bleeding, fatigue and a change in bowel patterns. Has several days of constipation alternating with diarrhea. ",
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Date / Time: Nov 1, 2011 August 6, 2012
347
Height 69 inches 69 inches
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Weight 189 lbs 194 lbs
349
Blood Pressure 132/86 mmHg 145/88 mmHg