Process Medical Summary Document Extractor — HIPAA Compliant

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                        DISCHARGE SUMMARY
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MERCY GENERAL HOSPITAL
4500 Healthcare Drive
Denver, CO 80202
Phone: (303) 555-1000

Department: Internal Medicine - 4 West
Document Status: FINAL

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                        PATIENT INFORMATION
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{
  "document_type": "medical_summary",
  "summary_type": "discharge",
  "document_date": "2024-01-10",
  "document_status": "Final",
  "facility_info": {
    "facility_name": "Mercy General Hospital",
    "facility_type": "Hospital",
    "address": "4500 Healthcare Drive, Denver, CO 80202",
    "phone": "(303) 555-1000",
    "department": "Internal Medicine - 4 West"
  },
  "patient_demographics": {
    "name": "DAVIS, MARGARET ANN",
    "date_of_birth": "1952-05-18",
    "age": 71,
    "gender": "Female",
    "mrn": "MRN-776655",
    "account_number": "IP-2024-112233"
  },
  "encounter_info": {
    "admission_date": "2024-01-05",
    "admission_time": "14:30",
    "discharge_date": "2024-01-10",
    "discharge_time": "11:00",
    "length_of_stay": 5,
    "admission_type": "Emergency",
    "admission_source": "Emergency Department",
    "discharge_disposition": "Home with Home Health Services (06)"
  },
  "care_team": {
    "attending_physician": {
      "name": "Dr. William Patterson, MD",
      "specialty": "Internal Medicine",
      "npi": "1234567890"
    },
    "admitting_physician": "Dr. Jennifer Liu, MD",
    "consulting_physicians": [
      {
        "name": "Dr. David Kim, MD",
        "specialty": "Pulmonology",
        "reason": "Management of community-acquired pneumonia"
      },
      {
        "name": "Dr. Sarah Thompson, MD",
        "specialty": "Infectious Disease",
        "reason": "Antibiotic selection and monitoring"
      }
    ],
    "primary_care_physician": "Dr. Robert Garcia, MD",
    "surgeon": null
  },
  "chief_complaint": "Shortness of breath, productive cough, and fever x 3 days",
  "history_of_present_illness": "Mrs. Davis is a 71-year-old female with a history of COPD, type 2 diabetes, and hypertension who presented to the ED with a 3-day history of worsening shortness of breath, productive cough with yellow-green sputum, and fever up to 102.4F at home. She reports decreased oral intake and increased fatigue. Denies chest pain, hemoptysis, or recent travel. She received her annual flu vaccine but has not received the pneumococcal vaccine.",
  "past_medical_history": [
    {
      "condition": "COPD - Gold Stage II",
      "icd_code": "J44.1",
      "status": "Chronic",
      "onset_date": "2018"
    },
    {
      "condition": "Type 2 Diabetes Mellitus",
      "icd_code": "E11.9",
      "status": "Chronic",
      "onset_date": null
    },
    {
      "condition": "Essential Hypertension",
      "icd_code": "I10",
      "status": "Chronic",
      "onset_date": null
    },
    {
      "condition": "Osteoarthritis - bilateral knees",
      "icd_code": "M17.0",
      "status": "Chronic",
      "onset_date": null
    },
    {
      "condition": "Hypothyroidism",
      "icd_code": "E03.9",
      "status": "Chronic",
      "onset_date": null
    }
  ],
  "past_surgical_history": [
    {
      "procedure": "Cholecystectomy",
      "date": "2005",
      "surgeon": null
    },
    {
      "procedure": "Right total knee replacement",
      "date": "2019",
      "surgeon": null
    },
    {
      "procedure": "Cataract surgery bilateral",
      "date": "2021",
      "surgeon": null
    }
  ],
  "family_history": [],
  "social_history": null,
  "allergies": [
    {
      "allergen": "Penicillin",
      "reaction": "Rash",
      "severity": "Moderate",
      "verified": true
    },
    {
      "allergen": "Codeine",
      "reaction": "Nausea/Vomiting",
      "severity": "Mild",
      "verified": true
    },
    {
      "allergen": "Latex",
      "reaction": "Contact dermatitis",
      "severity": "Mild",
      "verified": true
    }
  ],
  "admission_diagnoses": [
    {
      "diagnosis": "Community-acquired pneumonia",
      "icd_code": "J18.9",
      "type": "Principal",
      "poa": "Y"
    },
    {
      "diagnosis": "Acute hypoxic respiratory failure",
      "icd_code": "J96.01",
      "type": "Secondary",
      "poa": "Y"
    },
    {
      "diagnosis": "COPD with acute exacerbation",
      "icd_code": "J44.1",
      "type": "Secondary",
      "poa": "Y"
    },
    {
      "diagnosis": "Type 2 diabetes mellitus",
      "icd_code": "E11.9",
      "type": "Secondary",
      "poa": "Y"
    }
  ],
  "discharge_diagnoses": [
    {
      "diagnosis": "Community-acquired pneumonia, resolving",
      "icd_code": "J18.9",
      "type": "Principal"
    },
    {
      "diagnosis": "Acute hypoxic respiratory failure, resolved",
      "icd_code": "J96.01",
      "type": "Secondary"
    },
    {
      "diagnosis": "COPD with acute exacerbation, improved",
      "icd_code": "J44.1",
      "type": "Secondary"
    },
    {
      "diagnosis": "Type 2 diabetes mellitus, stable",
      "icd_code": "E11.9",
      "type": "Secondary"
    },
    {
      "diagnosis": "Essential hypertension, stable",
      "icd_code": "I10",
      "type": "Secondary"
    }
  ],
  "procedures_performed": [],
  "hospital_course": "Mrs. Davis was admitted through the ED with community-acquired pneumonia and hypoxic respiratory failure requiring 4L supplemental oxygen via nasal cannula. Chest X-ray showed right lower lobe infiltrate. Blood cultures were obtained and were negative. Sputum culture grew Streptococcus pneumoniae. She was started on IV ceftriaxone 1g daily and azithromycin 500mg daily (given penicillin allergy). Pulmonology was consulted and recommended continuation of antibiotics with transition to oral therapy. Infectious disease concurred with the antibiotic regimen. Her oxygen requirements gradually decreased over the hospitalization. By day 3, she was weaned to 2L NC, and by day 4, she was on room air with saturations maintained at 94-96%. Her cough improved significantly with decreased sputum production. Her diabetes was managed with her home medications with good glycemic control (BG 120-180 mg/dL range). Blood pressure remained well controlled throughout the stay. She was deemed safe for discharge on day 5 with completion of oral antibiotics, home oxygen for exertion only, and home health nursing for medication management and assessment.",
  "physical_exam": null,
  "admission_medications": [],
  "discharge_medications": [
    {
      "medication": "Metformin",
      "dose": "1000mg",
      "frequency": "Twice daily",
      "route": "PO",
      "duration": null,
      "new_medication": false,
      "changed": false,
      "discontinued": false,
      "instructions": "Take with meals (Diabetes)"
    },
    {
      "medication": "Lisinopril",
      "dose": "20mg",
      "frequency": "Once daily",
      "route": "PO",
      "duration": null,
      "new_medication": false,
      "changed": false,
      "discontinued": false,
      "instructions": "Hypertension"
    },
    {
      "medication": "Levothyroxine",
      "dose": "75mcg",
      "frequency": "Once daily",
      "route": "PO",
      "duration": null,
      "new_medication": false,
      "changed": false,
      "discontinued": false,
      "instructions": "Take in the morning (Thyroid)"
    },
    {
      "medication": "Albuterol inhaler",
      "dose": "2 puffs",
      "frequency": "Every 4-6 hours as needed",
      "route": "Inhaled",
      "duration": null,
      "new_medication": false,
      "changed": false,
      "discontinued": false,
      "instructions": "COPD"
    },
    {
      "medication": "Tiotropium",
      "dose": "18mcg",
      "frequency": "Once daily",
      "route": "Inhaled",
      "duration": null,
      "new_medication": false,
      "changed": false,
      "discontinued": false,
      "instructions": "COPD"
    },
    {
      "medication": "Azithromycin",
      "dose": "250mg",
      "frequency": "Once daily",
      "route": "PO",
      "duration": "3 more days",
      "new_medication": true,
      "changed": false,
      "discontinued": false,
      "instructions": "Complete full course - take with or without food (Pneumonia)"
    },
    {
      "medication": "Prednisone",
      "dose": "40mg",
      "frequency": "Once daily",
      "route": "PO",
      "duration": "5 days then stop",
      "new_medication": true,
      "changed": false,
      "discontinued": false,
      "instructions": "Take in the morning with food (COPD exacerbation)"
    },
    {
      "medication": "Portable oxygen",
      "dose": "2L",
      "frequency": "With exertion as needed",
      "route": "Nasal cannula",
      "duration": "Until follow-up with pulmonology",
      "new_medication": true,
      "changed": false,
      "discontinued": false,
      "instructions": "Use with walking until follow-up with pulmonology"
    }
  ],
  "discharge_instructions": {
    "activity": "May resume normal activities as tolerated. Use supplemental oxygen with exertion as instructed. Avoid strenuous activity until follow-up with pulmonologist.",
    "diet": "Regular diet, diabetic appropriate. Increase fluid intake to thin secretions. Continue monitoring blood sugars as usual.",
    "wound_care": "N/A",
    "symptoms_to_watch": [
      "Worsening shortness of breath",
      "Fever greater than 101.5F",
      "Chest pain",
      "Coughing up blood",
      "Confusion or altered mental status",
      "Oxygen saturation below 90% on room air"
    ],
    "restrictions": [
      "Avoid strenuous activity until follow-up"
    ],
    "when_to_seek_care": "Return to the emergency department immediately if you experience severe shortness of breath, chest pain, high fever, or feel significantly worse."
  },
  "follow_up_appointments": [
    {
      "provider": "Dr. Robert Garcia",
      "specialty": "Primary Care",
      "timeframe": "Within 7 days",
      "scheduled_date": null,
      "phone": "(303) 555-2000",
      "reason": "Post-hospitalization check, medication review"
    },
    {
      "provider": "Dr. David Kim",
      "specialty": "Pulmonology",
      "timeframe": "Within 2 weeks",
      "scheduled_date": null,
      "phone": "(303) 555-3000",
      "reason": "Follow-up on pneumonia, assess oxygen needs, COPD management"
    },
    {
      "provider": "ComfortCare Home Health",
      "specialty": "Home Health Nursing",
      "timeframe": null,
      "scheduled_date": "2024-01-11",
      "phone": "(303) 555-4000",
      "reason": "Medication management, assessment, oxygen therapy monitoring"
    }
  ],
  "pending_results": [],
  "code_status": "Full Code",
  "advance_directives": {
    "living_will": false,
    "healthcare_proxy": "Michael Davis (son)",
    "polst": false
  },
  "functional_status": null,
  "discharge_condition": "Improved/Stable",
  "signatures": {
    "author": "Dr. William Patterson, MD",
    "author_credentials": "MD",
    "signed_date": "2024-01-10",
    "cosigner": null
  },
  "validation": {
    "all_sections_complete": true,
    "diagnoses_coded": true,
    "medications_reconciled": true,
    "follow_up_documented": true
  }
}