63 lines
6.1 KiB
Plaintext
63 lines
6.1 KiB
Plaintext
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* indicates alternative standard code per certification criteria
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Patient Summary Record Test Data <20> Set #1
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Patient
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Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
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John D. Smith 07/04/1960 Male 999999999 Medical Record Number 355 Maple Street
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10:15:02 Williamsport,
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Pennsylvania 17701
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570-837-8364
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<EFBFBD>Source<EFBFBD> for all data for this patient: John Fitzgerald, MD
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Problem List
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Type ICD-9 Code Patient Problem Status Date Diagnosed
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Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 09/16/2009
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Condition 272.4 Hyperlipidemia Active 05/05/2002
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Finding 414.01 Coronary Artery Disease (CAD) Chronic 05/05/2002
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Symptom 401.9 Hypertension, Essential Active 05/05/2002
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Type SNOMED Code* Patient Problem Status Date Diagnosed
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Disorder 44054006 Diabetes Mellitus, Type 2 Active 09/16/2009
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Disorder 55822004 Hyperlipidemia Active 05/05/2002
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Disorder 53741008 Coronary Arteriosclerosis Chronic 05/05/2002
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Disorder 59621000 Essential Hypertension Active 05/05/2002
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Medication List
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RxNorm
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Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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Code
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205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 09/16/2009 Active
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atorvastatin
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617314 Medication Lipitor 10 mg 1 Tablet PO Q Day 05/05/2002 Active
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calcium
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RxNorm
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Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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Code
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200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 05/05/2002 Active
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potassium
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628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 05/05/2002 Active
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chloride
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Medication Allergy List
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Type SNOMED Code Medication/Agent Reaction Date Recorded
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Drug Allergy 293597001 Codeine Hives 06/27/1996
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Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/15/1994
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Diagnostic Test Results
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Type LOINC Code Test (Normal Range) Result Date Performed
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Chemistry 14771-0 Fasting Blood Glucose (70<37>100 mg/dl) 178 mg/dl 09/16/2009
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Chemistry 14682-9 Creatinine (0.5<EFBFBD>1.4 mg/dl) 1.0 mg/dl 09/16/2009
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Chemistry 14937-7 BUN (7<>30 mg/dl) 18 mg/dl 09/16/2009
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Chemistry 2951-2 Sodium (135<33>146 mg/dl) 141 mg/dl 09/16/2009
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Chemistry 2823-3 Potassium (3.5<EFBFBD>5.3 mg/dl) 4.3 mg/dl 09/16/2009
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Chemistry 14647-2 Total cholesterol (<200 mg/dl) 162 mg/dl 09/16/2009
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Chemistry 14646-4 HDL cholesterol (?40 mg/dl) 43 mg/dl 09/16/2009
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Chemistry 2089-1 LDL cholesterol (<100 mg/dl) 84 mg/dl 09/16/2009
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Chemistry 14927-8 Triglycerides (<150 mg/dl) 177 mg/dl 09/16/2009
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No disease is seen in the
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Imaging 24648-8 Chest X-ray, PA 09/16/2009
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lung fields or pleura
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