48 lines
2.4 KiB
Plaintext
48 lines
2.4 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 10:15:02|Male|999999999|Medical Record Number|355 Maple Street <br>Williamsport, <br>Pennsylvania 17701 <br>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 Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|09/16/2009|Active
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617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|05/05/2002|Active
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200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|05/05/2002|Active
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628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|05/05/2002|Active
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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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Imaging|24648-8|Chest X-ray, PA|No disease is seen in the<br>lung fields or pleura |09/16/2009
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