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LOGAN, REBECCA Admin Sex: Female DOB: 12/11/1989Continuity of Care DocumentSummarization of Episode Note Street Address /6/2023 to 10/6/2023 Source: University Medical CenterCreated: Street Address /21/2024DemographicsContact Information:1005 S SELMAN STHOBBS, NM 882407266, USATel: PHONE NUMBER AVAILABLETel: PHONE NUMBER AVAILABLEMail: EMAIL AVAILABLEMarital Status: SingleReligion: No Religious PrefRace: WhitePrevious Name(s): --Ethnic Group: Not Hispanic or LatinoLanguage: EnglishID: 811826, 8133438, URN:CERNER:IDENTITY-FEDERATION:REALM:2RN95TVX9SVNWZUXVBJAMHOPJ5VJNRTA- CH:PRINCIPAL:265A3ADA-4226-4AA4-8F8F-BD1F9D95C326Care TeamNo Data to DisplayRelationshipsNo Data to DisplayDocument DetailsSource Contact InfoPO BOX 5980ATTN: AMY EADELUBBOCK, TX 79407-, USATel: PHONE NUMBER AVAILABLEAuthor Contact Info--Recipient Contact Info--Healthcare ProfessionalsNo Data to DisplayIDs & Code Type DataDocument Type ID: 2.16.840.1.113883.1.3 : POCD_HD000040 Document Template ID: 2.16.840.1.113883.10.20.22.1.1 : --, 2.16.840.1.113883.10.20.22.1.1 : 2015-08-01, 2.16.840.1.113883.10.20.22.1.2: 2015-08-01Document ID: 2.16.840.1.113883.3.869.999362 : 89782376 Document Type Code: 2.16.840.1.113883.6.1, 34133-9 Document Language Code: en-USDocument Set ID: --Document Version Number: --Primary EncounterEncounter InformationRegistration Date: 10/6/2023Discharge Date: 10/6/2023Visit ID: --Location InformationUniversity Medical CenterWork:602 Indiana AvenueLubbock, TX 79415-, USAProvidersType Name Address PhoneAttending Leech, Alexa Work:602 IndianaAvenueLubbock, TX 79415-,USAWork Tel: PHONE NUMBER AVAILABLEEncounterUMCFIN 53217377 Date(s): 10/6/23 - 10/6/23University Medical Center 602 Indiana Avenue Lubbock, TX 79415- US PHONE NUMBER AVAILABLE Encounter DiagnosisEncounter for drug screening (Discharge Diagnosis) - 10/6/23 Encounter for blood-alcohol and blood-drug test (Final) - 11/14/23 Tobacco use (Final) - 11/14/23Discharge Disposition: HomeAttending Physician: Alexa Leech, APRNReason for VisitBLOOD DRUG TEST AND URIAN DRUGTESTAllergies, Adverse Reactions, AlertsNo Known AllergiesAssessment and PlanNo data available for this sectionImmunizationsNo data available for this sectionMedicationsmultivitamin, prenatalStatus: OrderedStart Date: 12/11/221 tab(s) by mouth Once a day.Problem ListCondition Confirmation Course Effective Dates Status Health Status Informant Pregnancy,obstetrical careConfirmed 12/11/22 -03/2023ResolvedProceduresNo data available for this sectionResultsLaboratory ListName DateUrine Random Drug Screen 10/6/23Chlamydia trachomatis by PCR 10/6/23Neisseria gonorrhoeae by PCR 10/6/2310/6/23Test Result Reference Range Specimen Source Laboratory Urine AmphetamineScreenNegative 1 (Normal is Negative) Urine LabUrine Barbituate Screen Negative 2 (Normal is Negative) Urine Lab Urine BenzodiazepineScreenNegative 3 (Normal is Negative) Urine LabUrine Cannabinoid Screen Negative 4 (Normal is Negative) Urine Lab Urine Cocaine Screen Negative 5 (Normal is Negative) Urine Lab Urine Opiate Screen Negative 6 (Normal is Negative) Urine Lab Chlamydia trachomatis byPCRNot Detected (Normal is Not Detected) Urine LabNeisseria gonorrhoeaePCRNot Detected (Normal is Not Detected) Urine Lab1 Interpretive Data: Cutoff, 1000ng/mLThese results should be used for medical purposes only. For any other purpose, confirmation by Gas Chromatography/Mass Spectrophotometry should be performed. Call the UMC Laboratory at PHONE NUMBER AVAILABLE for specimen availability. 2 Interpretive Data: Cutoff, 200ng/mL3 Interpretive Data: Cutoff, 300ng/mL4 Interpretive Data: Cutoff, 50ng/mL5 Interpretive Data: Cutoff, 300ng/mL6 Interpretive Data: Cutoff, 300ng/mLLaboratory InformationLabCLIA Number: 45D0660741602 Indiana AvenueLubbock, zzTexas USLabCLIA Number: 45D0660741602 Indiana AvenueLubbock, zzTexas USVital Signs10/6/23Height (in) 61.8 inchHeight (cm) 157 cmWeight (kg) 65.4 kgHeart Rate 59 bpm*LOW* (Normal is 60-100 bpm)Blood Pressure 125/85 mmHg (Normal is 94-140/60-90 mmHg) Respiratory Rate 16 breaths/min (Normal is 12-30 breaths/min) Oxygen Saturation 98 % (Normal is 90-100 %)O2 Therapy Room airTemperature TemporalArtery97.1 DegF (Normal is 96-101 DegF)Body Mass Index (cm) 26.53 kg/m2Social HistorySocial History Type ResponseSmoking Status Former smoker, quit more than 30 days ago; Never entered on: 10/6/23Birth Sex FemaleGoalsNo data available for this sectionHospital Discharge InstructionsSection Author: Leech, Alexa, University Medical Center Patient Education10/06/2023 18:21:44Substance Abuse TestingSubstance Abuse TestingWhy am I having this test?Substance use testing is done to identify the presence of drugs in the body. You may have this test to measure the levels of drugs or certain medicines in your body.Substance use testing is most often used by employers and law enforcement agencies to identify whether a person has used drugs. You may also have this test if you are involved in an accident at work. What is being tested?A substance use test may check for: Medicines that you have been prescribed, such as pain medicine or ADHD (attention deficit hyperactivity disorder) medicine. Drugs such as heroin, cocaine, and amphetamines. What kind of sample is taken?Your health care provider may collect one or more of the following to perform the test: A urine sample. A test sample is collected by passing urine into a clean cup. A hair sample. This requires cutting a collection of hair from your head or body that is about the width of a pencil. Hair may be taken from your head, chest, underarms, legs, or face. A blood sample. This is usually collected by inserting a needle into a blood vessel. How do I prepare for this test?You may be asked to provide a list of your current prescription medicines. If the test is required for employment or legal reasons, you will be asked to give permission (consent) for the test. Before providing a sample, you may be asked to put all of your belongings in a locker or other safe location, and you may be asked to wash your hands.Follow the specific directions of the lab or department that is doing the test. Tell a health care provider about: Any allergies you have. All medicines you are taking, including vitamins, herbs, eye drops, creams, and over-the-counter medicines. Any bleeding problems you have. Any surgeries you have had. Any medical conditions you have. Whether you are pregnant or may be pregnant.How are the results reported?Your test results will be reported as either positive or negative. What do the results mean?A negative test result means that no drugs or medicines were found in the sample that you provided. A positive test result may mean that you have recently used drugs or taken a medicine. If your result is positive, more testing will be done to confirm the presence of drugs.Talk with your health care provider or the department that is doing the test about what your results mean. Questions to ask your health care providerAsk your health care provider, or the department that is doing the test: When will my results be ready? How will I get my results? What other tests do I need? What are my next steps?Summary Substance use testing is done to identify the presence of drugs in the body. Substance use testing is most often used by employers and law enforcement agencies to identify whether a person has used drugs. You may also have this test if you are involved in an accident at work. You may be asked to provide a list of your current prescription medicines. If the test is required for employment or legal reasons, you will be asked to give permission (consent) for the test. This information is not intended to replace advice given to you by your health care provider. Make sure you discuss any questions you have with your health care provider.Document Revised: 04/15/2022 Document Reviewed: 04/15/2022 Elsevier Patient Education  2023 Elsevier Inc.Follow Up Care10/06/2023 11:55:28With: Your primary care provider within 1 to 2 weeks Address:When:UnknownReason for ReferralNo data available for this sectionHealth ConcernsNo data available for this sectionImplantable Device ListNo data available for this sectionNoteAlexa Leech, APRN: PERFORMEvent Display: Urgent Care Office/Clinic NoteAuthored Date: PHONE NUMBER AVAILABLEDate of Service 10/06/2023 11:54:40Chief Complaintpt here for personal urine drug screen d/t baby testing + for marijuanna. History of Present IllnessPt. presents to urgent care wanting a urine drug test because her baby tested positive for marijuana and she wants to prove that she is clean. Pt. is also concerned about gonorrhea and chlamydia and would like a test for that as wellReview of SystemsConstitutional: no fever, no chills, no weakness.Eye: no acute visual problems, no dischargeENMT: no ear pain, no sore throat, no congestionSkin: no itching, no rash, no lesionsRespiratory: no shortness of breath, no coughCardiovascular: no chest pain, no edema.Gastrointestinal: no nausea, no vomiting, no diarrhea, no abdominal pain Genitourinary: no dysuria, no hematuria, no discharge Immunologic: not immunocompromised/chemotherapyMusculoskeletal: no trauma.Neurologic: no headache, no dizzinessAllergy/Immunologic: NKDAAdditional ROS info: Except as noted in the above Review of Symptoms and in the History of Present Illness, all other systems have been reviewed and are negative or noncontributory. Physical ExamVitals & MeasurementsT: 97.1 F (Temporal Artery) HR: 59(Monitored) RR: 16 BP: 125/85 SpO2: 98% HT: 157 cm WT: 65.4 kg BMI: 26.53Pain Symptoms: NoGeneral: alert, no acute distress.Skin: warm, dry.Eye: normal conjunctiva, sclera clear.Head: no trauma, normocephalic.Neck: trachea midline, no adenopathy, no tenderness. Cardiovascular: regular rate and rhythm, no peripheral edema Respiratory: Lungs CTA, respirations non labored.Extremities: no acute deformity.Neurological: oriented X 4, LOC appropriate for age, speech normal. Psychiatric: cooperativeAssessment/PlanEncounter for drug screening Z02.83Discussed with pt. her resultsMake and keep follow-up appointmentsOrdered:Urine Random Drug ScreenOrders:Chlamydia trachomatis by PCRNeisseria gonorrhoeae by PCREvaluation and Management99213 Established Patient, expanded hx and exam, low mdm, office or other outpatient visit - Completed-- Encounter for drug screeningPatient EducationSubstance Abuse TestingFollow UpWith When Contact Information Your primary care provider within 1 to 2 weeks Additional Instructions:Past Medical HistoryHistoricalPregnancy, obstetrical careMedicationsmultivitamin, prenatal, 1 tab, PO, Daily, Not taking AllergiesNo Known AllergiesSocial HistoryAlcoholAlcohol Use: Never used., 10/06/2023TobaccoTobacco Use: Former smoker, quit more than 30 days ago. Smokeless Tobacco Use: Never., 10/06/2023VapingVaping Device Use: Current User. Nicotine Use: Yes., 10/06/2023 Alexa Leech, APRNElectronically Signed On: 10.06.2023 18:22/ALD: 10.06.2023 18:22cc:Patient Care team informationCare Team Related PersonsName: LOGAN, PBREBECCAAddress: home300 NW AVESEMINOLE, 79359Name: NONE, PER PTFamily HistoryNo data available for this section