37 lines
1.8 KiB
Plaintext
37 lines
1.8 KiB
Plaintext
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Test<EFBFBD>Procedure<EFBFBD>for<EFBFBD><EFBFBD>170.304.h<>Clinical<61>Summaries<65>
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APPROVED<EFBFBD>(Pending)<29>Version<6F>1.0<EFBFBD><EFBFBD>July<EFBFBD>21,<2C>2010<31><30>
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TD170.304.h.: Clinical summaries
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* indicates alternative standard code per certification criteria
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Clinical Summaries Test Data <20> Set #3|Office Visit #2 for Barbara Simpson
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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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Barbara Simpson|10/12/1956 19:47:01|Female|9688675266|Medical Record Number|996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534
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<EFBFBD>Source<EFBFBD> for all data for this patient: Robert James, 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|496.0|Chronic Obstructive Pulmonary Disease|Chronic|02/10/2010
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Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|02/10/2010
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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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836370|Medication|ipratropium bromide monohydrate|Atrovent Inhaler|18 mcg/puff|2 Puffs|Inhaled|QID|02/10/2010|Active
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630208|Medication|albuterol sulfate|Albuterol Inhaler|2.5 mg/3ml|2 Puffs|Inhaled|Q 4 hours as needed|02/10/2010|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|91936005|Penicillin|Rash and anaphylaxis|06/10/2009
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Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988
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Diagnostic Test Results
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Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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Imaging|42272-5|Chest X-ray, PA & Lateral|Hyperinflated lungs with flattened diaphragm and central pulmonary artery enlargement|02/10/2010
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Hematology|718-7|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)|16 g/dl|02/10/2010
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Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|45%|02/10/2010
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