Add ambulatory test patients 2-5
This commit is contained in:
parent
a2fa042af5
commit
b0b9cebb0a
|
@ -0,0 +1,162 @@
|
||||||
|
Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary Record
|
||||||
|
APPROVED (Pending) Version 1.0 July 21, 2010
|
||||||
|
|
||||||
|
Patient Summary Record Test Data – Set #2
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="6"|Patient
|
||||||
|
|----
|
||||||
|
!scope="col"|Name
|
||||||
|
!scope="col"|Date/Time of Birth
|
||||||
|
!scope="col"|Gender
|
||||||
|
!scope="col"|Identification Number
|
||||||
|
!scope="col"|Identification Number Type
|
||||||
|
!scope="col"|Address/Phone
|
||||||
|
|----
|
||||||
|
|Ralph Johnson
|
||||||
|
|06/28/1984 13:20:10
|
||||||
|
|Male
|
||||||
|
|9813466798
|
||||||
|
|Medical Record Number
|
||||||
|
|355 Elm Street<br>Morton,<br>Illinois 61550<br>309-377-8365
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
“Source” for all data for this patient: Carl Roberts, MD
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="6"|Problem List
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|ICD-9 Code
|
||||||
|
!scope="col"|Patient Problem
|
||||||
|
!scope="col"|Status
|
||||||
|
!scope="col"|Date Diagnosed
|
||||||
|
|----
|
||||||
|
|Diagnosis
|
||||||
|
|493.00
|
||||||
|
|Asthma, unspecified
|
||||||
|
|Active
|
||||||
|
|12/22/2009
|
||||||
|
|----
|
||||||
|
|Diagnosis
|
||||||
|
|250.02
|
||||||
|
|Diabetes Mellitus, Type 2
|
||||||
|
|Active
|
||||||
|
|08/10/2008
|
||||||
|
|----
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|SNOMED Code*
|
||||||
|
!scope="col"|Patient Problem
|
||||||
|
!scope="col"|Status
|
||||||
|
!scope="col"|Date Diagnosed
|
||||||
|
|----
|
||||||
|
|Disorder
|
||||||
|
|195967001
|
||||||
|
|Asthma
|
||||||
|
|Active
|
||||||
|
|12/22/2009
|
||||||
|
|----
|
||||||
|
|Disorder
|
||||||
|
|44054006
|
||||||
|
|Diabetes Mellitus, Type 2
|
||||||
|
|Active
|
||||||
|
|08/10/2008
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="10"|Medication List
|
||||||
|
|----
|
||||||
|
!scope="col"|RxNorm Code
|
||||||
|
!scope="col"|Product
|
||||||
|
!scope="col"|Generic Name
|
||||||
|
!scope="col"|Brand Name
|
||||||
|
!scope="col"|Strength
|
||||||
|
!scope="col"|Dose
|
||||||
|
!scope="col"|Route
|
||||||
|
!scope="col"|Frequency
|
||||||
|
!scope="col"|Date Started
|
||||||
|
!scope="col"|Status
|
||||||
|
|----
|
||||||
|
|206833
|
||||||
|
|Medication
|
||||||
|
|metaproternol sulfate
|
||||||
|
|Alupent Inhalation Aerosol
|
||||||
|
|15 mg/ml
|
||||||
|
|2 Puffs
|
||||||
|
|Inhaled
|
||||||
|
|Q4h
|
||||||
|
|12/22/2009
|
||||||
|
|Active
|
||||||
|
|----
|
||||||
|
|205875
|
||||||
|
|Medication
|
||||||
|
|glyburide
|
||||||
|
|Diabeta
|
||||||
|
|2.5 mg
|
||||||
|
|1 Tablet
|
||||||
|
|PO
|
||||||
|
|Q AM
|
||||||
|
|08/10/2008
|
||||||
|
|Active
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="5"|Medication Allergy List
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|SNOMED Code
|
||||||
|
!scope="col"|Medication/Agent
|
||||||
|
!scope="col"|Reaction
|
||||||
|
!scope="col"|Date Recorded
|
||||||
|
|----
|
||||||
|
|Drug Allergy
|
||||||
|
|91936005
|
||||||
|
|Penicillin
|
||||||
|
|Rash and anaphylaxis
|
||||||
|
|08/10/2008
|
||||||
|
|----
|
||||||
|
|Drug Allergy
|
||||||
|
|293620004
|
||||||
|
|Indomethacin
|
||||||
|
|Nausea, vomiting, rash,<br>dizziness, headache
|
||||||
|
|03/25/2003
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="5"|Diagnostic Test Results
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|LOINC Code
|
||||||
|
!scope="col"|Test (Normal Range)
|
||||||
|
!scope="col"|Result
|
||||||
|
!scope="col"|Date Performed
|
||||||
|
|----
|
||||||
|
|Imaging
|
||||||
|
|24648-8
|
||||||
|
|Chest X-ray, PA
|
||||||
|
|Increased bronchial wall<br>markings, patchy infiltrates
|
||||||
|
|02/16/2010
|
||||||
|
|----
|
||||||
|
|Chemistry
|
||||||
|
|14771-0
|
||||||
|
|Fasting Blood Glucose (70–100 mg/dl)
|
||||||
|
|70 mg/dl
|
||||||
|
|12/22/2009
|
||||||
|
|----
|
||||||
|
|Hematology
|
||||||
|
|26449-9
|
||||||
|
|Eosinophil Count (1 – 3 %)
|
||||||
|
|2%
|
||||||
|
|12/22/2009
|
||||||
|
|----
|
||||||
|
|Imaging
|
||||||
|
|24648-8
|
||||||
|
|Chest X-ray, PA
|
||||||
|
|Bronchial wall markings
|
||||||
|
|12/22/2009
|
||||||
|
|----
|
|
@ -0,0 +1,35 @@
|
||||||
|
Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary Record
|
||||||
|
APPROVED (Pending) Version 1.0 July 21, 2010
|
||||||
|
|
||||||
|
Patient Summary Record Test Data – Set #2
|
||||||
|
|
||||||
|
Patient
|
||||||
|
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||||
|
Ralph Johnson|06/28/1984 13:20:10|Male|9813466798|Medical Record Number|355 Elm Street<br>Morton,<br>Illinois 61550<br>309-377-8365
|
||||||
|
|
||||||
|
“Source” for all data for this patient: Carl Roberts, MD
|
||||||
|
|
||||||
|
Problem List
|
||||||
|
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||||
|
Diagnosis|493.00|Asthma, unspecified|Active|12/22/2009
|
||||||
|
Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|08/10/2008
|
||||||
|
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||||
|
Disorder|195967001|Asthma|Active|12/22/2009
|
||||||
|
Disorder|44054006|Diabetes Mellitus, Type 2|Active|08/10/2008
|
||||||
|
|
||||||
|
Medication List
|
||||||
|
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||||
|
206833|Medication|metaproternol sulfate|Alupent Inhalation Aerosol|15 mg/ml|2 Puffs|Inhaled|Q4h|12/22/2009|Active
|
||||||
|
205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|08/10/2008|Active
|
||||||
|
|
||||||
|
Medication Allergy List
|
||||||
|
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||||
|
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|08/10/2008
|
||||||
|
Drug Allergy|293620004|Indomethacin|Nausea, vomiting, rash,<br>dizziness, headache|03/25/2003
|
||||||
|
|
||||||
|
Diagnostic Test Results
|
||||||
|
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||||
|
Imaging|24648-8|Chest X-ray, PA|Increased bronchial wall<br>markings, patchy infiltrates|02/16/2010
|
||||||
|
Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|70 mg/dl|12/22/2009
|
||||||
|
Hematology|26449-9|Eosinophil Count (1 – 3 %)|2%|12/22/2009
|
||||||
|
Imaging|24648-8|Chest X-ray, PA|Bronchial wall markings|12/22/2009
|
|
|
@ -0,0 +1,170 @@
|
||||||
|
Patient Summary Record Test Data – Set #3
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="6"|Patient
|
||||||
|
|----
|
||||||
|
!scope="col"|Name
|
||||||
|
!scope="col"|Date/Time of Birth
|
||||||
|
!scope="col"|Gender
|
||||||
|
!scope="col"|Identification Number
|
||||||
|
!scope="col"|Identification Number Type
|
||||||
|
!scope="col"|Address/Phone
|
||||||
|
|----
|
||||||
|
|Jane Andrews
|
||||||
|
|05/12/1955 09:30:15
|
||||||
|
|Female
|
||||||
|
|9639275266
|
||||||
|
|Medical Record Number
|
||||||
|
|355 1st Street<br>Fargo,<br>North Dakota 54102<br>701-366-8364
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
“Source” for all data for this patient: Robert James, MD
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="6"|Problem List
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|ICD-9 Code
|
||||||
|
!scope="col"|Patient Problem
|
||||||
|
!scope="col"|Status
|
||||||
|
!scope="col"|Date Diagnosed
|
||||||
|
|----
|
||||||
|
|Diagnosis
|
||||||
|
|486
|
||||||
|
|Pneumonia
|
||||||
|
|Resolved
|
||||||
|
|01/22/2010
|
||||||
|
|----
|
||||||
|
|Diagnosis
|
||||||
|
|496.0
|
||||||
|
|Chronic Obstructive Pulmonary Disease
|
||||||
|
|Chronic
|
||||||
|
|10/10/1999
|
||||||
|
|----
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|SNOMED Code*
|
||||||
|
!scope="col"|Patient Problem
|
||||||
|
!scope="col"|Status
|
||||||
|
!scope="col"|Date Diagnosed
|
||||||
|
|----
|
||||||
|
|Disorder
|
||||||
|
|233604007
|
||||||
|
|Pneumonia
|
||||||
|
|Resolved
|
||||||
|
|01/22/2010
|
||||||
|
|----
|
||||||
|
|Disorder
|
||||||
|
|13645005
|
||||||
|
|Chronic Obstructive Lung Disease
|
||||||
|
|Chronic
|
||||||
|
|10/10/1999
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="10"|Medication List
|
||||||
|
|----
|
||||||
|
!scope="col"|RxNorm Code
|
||||||
|
!scope="col"|Product
|
||||||
|
!scope="col"|Generic Name
|
||||||
|
!scope="col"|Brand Name
|
||||||
|
!scope="col"|Strength
|
||||||
|
!scope="col"|Dose
|
||||||
|
!scope="col"|Route
|
||||||
|
!scope="col"|Frequency
|
||||||
|
!scope="col"|Date Started
|
||||||
|
!scope="col"|Status
|
||||||
|
|----
|
||||||
|
|308460
|
||||||
|
|Medication
|
||||||
|
|azithromycin
|
||||||
|
|Azithromycin
|
||||||
|
|250 mg
|
||||||
|
|1 Tablet
|
||||||
|
|PO
|
||||||
|
|QD
|
||||||
|
|01/22/2010
|
||||||
|
|No Longer Active
|
||||||
|
|----
|
||||||
|
|836370
|
||||||
|
|Medication
|
||||||
|
|ipratropium bromide monhydrate
|
||||||
|
|Atrovent Inhaler
|
||||||
|
|18 mcg/puff
|
||||||
|
|2 Puffs
|
||||||
|
|Inhaled
|
||||||
|
|QID
|
||||||
|
|10/10/1999
|
||||||
|
|Active
|
||||||
|
|----
|
||||||
|
|630208
|
||||||
|
|Medication
|
||||||
|
|albuterol sulfate
|
||||||
|
|Albuterol Inhaler
|
||||||
|
|2.5 mg/3ml
|
||||||
|
|2 Puffs
|
||||||
|
|Inhaled
|
||||||
|
|Q 4 PRN
|
||||||
|
|10/10/1999
|
||||||
|
|Active
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="5"|Medication Allergy List
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|SNOMED Code
|
||||||
|
!scope="col"|Medication/Agent
|
||||||
|
!scope="col"|Reaction
|
||||||
|
!scope="col"|Date Recorded
|
||||||
|
|----
|
||||||
|
|Drug Allergy
|
||||||
|
|91936005
|
||||||
|
|Penicillin
|
||||||
|
|Rash and anaphylaxis
|
||||||
|
|06/10/2009
|
||||||
|
|----
|
||||||
|
|Drug Allergy
|
||||||
|
|91939003
|
||||||
|
|Sulfonamides
|
||||||
|
|Hives, photosensitivity
|
||||||
|
|04/25/1988
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="5"|Diagnostic Test Results
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|LOINC Code
|
||||||
|
!scope="col"|Test (Normal Range)
|
||||||
|
!scope="col"|Result
|
||||||
|
!scope="col"|Date Performed
|
||||||
|
|----
|
||||||
|
|42272-5
|
||||||
|
|Imaging
|
||||||
|
|Chest X-ray, PA & Lateral
|
||||||
|
|Hyperinflated lungs with<br>flattened diaphragm and<br>central pulmonary artery<br>enlargement
|
||||||
|
|02/15/2010
|
||||||
|
|----
|
||||||
|
|Hematology
|
||||||
|
|718-7
|
||||||
|
|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)
|
||||||
|
|16 g/dl
|
||||||
|
|12/22/2009
|
||||||
|
|----
|
||||||
|
|Hematology
|
||||||
|
|4544-3
|
||||||
|
|Hematocrit (male: 40-54%<br>female: 36-48%)
|
||||||
|
| 45%
|
||||||
|
|12/22/2009
|
||||||
|
|----
|
||||||
|
|Cardiology
|
||||||
|
|34534-8
|
||||||
|
|Electrocardiogram
|
||||||
|
|Normal Sinus Rhythm
|
||||||
|
|12/22/2009
|
||||||
|
|----
|
|
@ -0,0 +1,33 @@
|
||||||
|
Patient Summary Record Test Data – Set #3
|
||||||
|
|
||||||
|
Patient
|
||||||
|
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||||
|
Jane Andrews|05/12/1955 09:30:15|Female|9639275266|Medical Record Number|355 1st Street<br>Fargo,<br>North Dakota 54102<br>701-366-8364
|
||||||
|
|
||||||
|
“Source” for all data for this patient: Robert James, MD
|
||||||
|
|
||||||
|
Problem List
|
||||||
|
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||||
|
Diagnosis|486|Pneumonia|Resolved|01/22/2010
|
||||||
|
Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|10/10/1999
|
||||||
|
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||||
|
Disorder|233604007|Pneumonia|Resolved|01/22/2010
|
||||||
|
Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|10/10/1999
|
||||||
|
|
||||||
|
Medication List
|
||||||
|
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||||
|
308460|Medication|azithromycin|Azithromycin|250 mg|1 Tablet|PO|QD|01/22/2010|No Longer Active
|
||||||
|
836370|Medication|ipratropium bromide monhydrate|Atrovent Inhaler|18 mcg/puff|2 Puffs|Inhaled|QID|10/10/1999|Active
|
||||||
|
630208|Medication|albuterol sulfate|Albuterol Inhaler|2.5 mg/3ml|2 Puffs|Inhaled|Q 4 PRN|10/10/1999|Active
|
||||||
|
|
||||||
|
Medication Allergy List
|
||||||
|
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||||
|
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|06/10/2009
|
||||||
|
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988
|
||||||
|
|
||||||
|
Diagnostic Test Results
|
||||||
|
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||||
|
42272-5|Imaging|Chest X-ray, PA & Lateral|Hyperinflated lungs with<br>flattened diaphragm and<br>central pulmonary artery<br>enlargement|02/15/2010
|
||||||
|
Hematology|718-7|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)|16 g/dl|12/22/2009
|
||||||
|
Hematology|4544-3|Hematocrit (male: 40-54%<br>female: 36-48%)| 45%|12/22/2009
|
||||||
|
Cardiology|34534-8|Electrocardiogram|Normal Sinus Rhythm|12/22/2009
|
|
|
@ -0,0 +1,185 @@
|
||||||
|
Patient Summary Record Test Data – Set #4
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="6"|Patient
|
||||||
|
|----
|
||||||
|
!scope="col"|Name
|
||||||
|
!scope="col"|Date/Time of Birth
|
||||||
|
!scope="col"|Gender
|
||||||
|
!scope="col"|Identification Number
|
||||||
|
!scope="col"|Identification Number Type
|
||||||
|
!scope="col"|Address/Phone
|
||||||
|
|----
|
||||||
|
|Sally Eckerd
|
||||||
|
|08/08/1962 18:25:59
|
||||||
|
|Female
|
||||||
|
|998877799
|
||||||
|
|Medical Record Number
|
||||||
|
|754 Samuel Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-2981
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
“Source” for all data for this patient: Mark Payne, MD
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="6"|Problem List
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|ICD-9 Code
|
||||||
|
!scope="col"|Patient Problem
|
||||||
|
!scope="col"|Status
|
||||||
|
!scope="col"|Date Diagnosed
|
||||||
|
|----
|
||||||
|
|Condition
|
||||||
|
|272.4
|
||||||
|
|Hyperlipidemia
|
||||||
|
|Active
|
||||||
|
|07/05/2006
|
||||||
|
|----
|
||||||
|
|Symptom
|
||||||
|
|401.9
|
||||||
|
|Hypertension, Essential
|
||||||
|
|Active
|
||||||
|
|07/05/2006
|
||||||
|
|----
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|SNOMED Code*
|
||||||
|
!scope="col"|Patient Problem
|
||||||
|
!scope="col"|Status
|
||||||
|
!scope="col"|Date Diagnosed
|
||||||
|
|----
|
||||||
|
|Disorder
|
||||||
|
|55822004
|
||||||
|
|Hyperlipidemia
|
||||||
|
|Active
|
||||||
|
|07/05/2006
|
||||||
|
|----
|
||||||
|
|Disorder
|
||||||
|
|59621000
|
||||||
|
|Essential Hypertension
|
||||||
|
|Active
|
||||||
|
|07/05/2006
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="10"|Medication List
|
||||||
|
|----
|
||||||
|
!scope="col"|RxNorm Code
|
||||||
|
!scope="col"|Product
|
||||||
|
!scope="col"|Generic Name
|
||||||
|
!scope="col"|Brand Name
|
||||||
|
!scope="col"|Strength
|
||||||
|
!scope="col"|Dose
|
||||||
|
!scope="col"|Route
|
||||||
|
!scope="col"|Frequency
|
||||||
|
!scope="col"|Date Started
|
||||||
|
!scope="col"|Status
|
||||||
|
|----
|
||||||
|
|617314
|
||||||
|
|Medication
|
||||||
|
|atorvastatin calcium
|
||||||
|
|Lipitor
|
||||||
|
|10 mg
|
||||||
|
|1 Tablet
|
||||||
|
|PO
|
||||||
|
|Q Day
|
||||||
|
|07/05/2006
|
||||||
|
|Active
|
||||||
|
|----
|
||||||
|
|200801
|
||||||
|
|Medication
|
||||||
|
|furosemide
|
||||||
|
|Lasix
|
||||||
|
|20 mg
|
||||||
|
|1 Tablet
|
||||||
|
|PO
|
||||||
|
|BID
|
||||||
|
|07/05/2006
|
||||||
|
|Active
|
||||||
|
|----
|
||||||
|
|628958
|
||||||
|
|Medication
|
||||||
|
|potassium chloride
|
||||||
|
|Klor-Con
|
||||||
|
|10 mEq
|
||||||
|
|1 Tablet
|
||||||
|
|PO
|
||||||
|
|BID
|
||||||
|
|07/05/2006
|
||||||
|
|Active
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="5"|Medication Allergy List
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|SNOMED Code
|
||||||
|
!scope="col"|Medication/Agent
|
||||||
|
!scope="col"|Reaction
|
||||||
|
!scope="col"|Date Recorded
|
||||||
|
|----
|
||||||
|
|Drug Allergy
|
||||||
|
|91936005
|
||||||
|
|Penicillin
|
||||||
|
|Rash and anaphylaxis
|
||||||
|
|05/22/1998
|
||||||
|
|----
|
||||||
|
|Drug Allergy
|
||||||
|
|293597001
|
||||||
|
|Codeine
|
||||||
|
|Hives
|
||||||
|
|02/17/1992
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="5"|Diagnostic Test Results
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|LOINC Code
|
||||||
|
!scope="col"|Test (Normal Range)
|
||||||
|
!scope="col"|Result
|
||||||
|
!scope="col"|Date Performed
|
||||||
|
|----
|
||||||
|
|Chemistry
|
||||||
|
|2823-3
|
||||||
|
|Potassium (3.5–5.3 mg/dl)
|
||||||
|
|4.5 mg/dl
|
||||||
|
|07/15/2009
|
||||||
|
|----
|
||||||
|
|Chemistry
|
||||||
|
|14647-2
|
||||||
|
|Total cholesterol (<200 mg/dl)
|
||||||
|
|180 mg/dl
|
||||||
|
|07/15/2009
|
||||||
|
|----
|
||||||
|
|Chemistry
|
||||||
|
|14646-4
|
||||||
|
|HDL cholesterol (?40 mg/dl)
|
||||||
|
|38 mg/dl
|
||||||
|
|07/15/2009
|
||||||
|
|----
|
||||||
|
|Chemistry
|
||||||
|
|2089-1
|
||||||
|
|LDL cholesterol (<100 mg/dl)
|
||||||
|
|120 mg/dl
|
||||||
|
|07/15/2009
|
||||||
|
|----
|
||||||
|
|Chemistry
|
||||||
|
|14927-8
|
||||||
|
|Triglycerides (<150 mg/dl)
|
||||||
|
|187 mg/dl
|
||||||
|
|07/15/2009
|
||||||
|
|----
|
||||||
|
|Imaging
|
||||||
|
|42272-5
|
||||||
|
|Chest X-ray, PA & Lateral
|
||||||
|
|The heart outline is normal<br>and the hilar and<br>mediastinal vessels are of<br>normal appearance
|
||||||
|
|07/15/2009
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
|
|
@ -0,0 +1,37 @@
|
||||||
|
Patient Summary Record Test Data – Set #4
|
||||||
|
|
||||||
|
Patient
|
||||||
|
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||||
|
Sally Eckerd|08/08/1962 18:25:59|Female|998877799|Medical Record Number|754 Samuel Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-2981
|
||||||
|
|
||||||
|
“Source” for all data for this patient: Mark Payne, MD
|
||||||
|
|
||||||
|
Problem List
|
||||||
|
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||||
|
Condition|272.4|Hyperlipidemia|Active|07/05/2006
|
||||||
|
Symptom|401.9|Hypertension, Essential|Active|07/05/2006
|
||||||
|
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||||
|
Disorder|55822004|Hyperlipidemia|Active|07/05/2006
|
||||||
|
Disorder|59621000|Essential Hypertension|Active|07/05/2006
|
||||||
|
|
||||||
|
Medication List
|
||||||
|
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||||
|
617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|07/05/2006|Active
|
||||||
|
200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|07/05/2006|Active
|
||||||
|
628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|07/05/2006|Active
|
||||||
|
|
||||||
|
Medication Allergy List
|
||||||
|
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||||
|
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|05/22/1998
|
||||||
|
Drug Allergy|293597001|Codeine|Hives|02/17/1992
|
||||||
|
|
||||||
|
Diagnostic Test Results
|
||||||
|
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||||
|
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.5 mg/dl|07/15/2009
|
||||||
|
Chemistry|14647-2|Total cholesterol (<200 mg/dl)|180 mg/dl|07/15/2009
|
||||||
|
Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|38 mg/dl|07/15/2009
|
||||||
|
Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|120 mg/dl|07/15/2009
|
||||||
|
Chemistry|14927-8|Triglycerides (<150 mg/dl)|187 mg/dl|07/15/2009
|
||||||
|
Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal<br>and the hilar and<br>mediastinal vessels are of<br>normal appearance|07/15/2009
|
||||||
|
|
||||||
|
|
|
|
@ -0,0 +1,172 @@
|
||||||
|
Patient Summary Record Test Data – Set #5
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="6"|Patient
|
||||||
|
|----
|
||||||
|
!scope="col"|Name
|
||||||
|
!scope="col"|Date/Time of Birth
|
||||||
|
!scope="col"|Gender
|
||||||
|
!scope="col"|Identification Number
|
||||||
|
!scope="col"|Identification Number Type
|
||||||
|
!scope="col"|Address/Phone
|
||||||
|
|----
|
||||||
|
|Matthew Brown
|
||||||
|
|09/22/1965 16:48:25
|
||||||
|
|Male
|
||||||
|
|988730987
|
||||||
|
|Medical Record Number
|
||||||
|
|754 Sharp Street<br>Aurora,<br>Colorado 80011<br>303-544-9988
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
“Source” for all data for this patient: Pamela Jones, MD
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="6"|Problem List
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|ICD-9 Code
|
||||||
|
!scope="col"|Patient Problem
|
||||||
|
!scope="col"|Status
|
||||||
|
!scope="col"|Date Diagnosed
|
||||||
|
|----
|
||||||
|
|Diagnosis
|
||||||
|
|250.02
|
||||||
|
|Diabetes Mellitus, Type 2
|
||||||
|
|Active
|
||||||
|
|07/17/2009
|
||||||
|
|----
|
||||||
|
|Symptom
|
||||||
|
|401.9
|
||||||
|
|Hypertension, Essential
|
||||||
|
|Active
|
||||||
|
|06/05/2008
|
||||||
|
|----
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|SNOMED Code*
|
||||||
|
!scope="col"|Patient Problem
|
||||||
|
!scope="col"|Status
|
||||||
|
!scope="col"|Date Diagnosed
|
||||||
|
|----
|
||||||
|
|Disorder
|
||||||
|
|44054006
|
||||||
|
|Diabetes Mellitus, Type 2
|
||||||
|
|Active
|
||||||
|
|07/17/2009
|
||||||
|
|----
|
||||||
|
|Disorder
|
||||||
|
|59621000
|
||||||
|
|Essential Hypertension
|
||||||
|
|Active
|
||||||
|
|06/05/2008
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="10"|Medication List
|
||||||
|
|----
|
||||||
|
!scope="col"|RxNorm Code
|
||||||
|
|----
|
||||||
|
|
|
||||||
|
|Product
|
||||||
|
|Generic Name
|
||||||
|
|Brand Name
|
||||||
|
|Strength
|
||||||
|
|Dose
|
||||||
|
|Route
|
||||||
|
|Frequency
|
||||||
|
|Date Started
|
||||||
|
|Status
|
||||||
|
|----
|
||||||
|
|205875
|
||||||
|
|Medication
|
||||||
|
|glyburide
|
||||||
|
|Diabeta
|
||||||
|
|2.5 mg
|
||||||
|
|1 Tablet
|
||||||
|
|PO
|
||||||
|
|Q AM
|
||||||
|
|07/17/2009
|
||||||
|
|Active
|
||||||
|
|----
|
||||||
|
|200801
|
||||||
|
|Medication
|
||||||
|
|furosemide
|
||||||
|
|Lasix
|
||||||
|
|20 mg
|
||||||
|
|1 Tablet
|
||||||
|
|PO
|
||||||
|
|BID
|
||||||
|
|06/05/2008
|
||||||
|
|Active
|
||||||
|
|----
|
||||||
|
|628958
|
||||||
|
|Medication
|
||||||
|
|potassium chloride
|
||||||
|
|Klor-Con
|
||||||
|
|10 mEq
|
||||||
|
|1 Tablet
|
||||||
|
|PO
|
||||||
|
|BID
|
||||||
|
|06/05/2008
|
||||||
|
|Active
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="5"|Medication Allergy List
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|SNOMED Code
|
||||||
|
!scope="col"|Medication/Agent
|
||||||
|
!scope="col"|Reaction
|
||||||
|
!scope="col"|Date Recorded
|
||||||
|
|----
|
||||||
|
|Drug Allergy
|
||||||
|
|294506009
|
||||||
|
|Ampicillin
|
||||||
|
|Diarrhea, nausea, vomiting
|
||||||
|
|03/25/1997
|
||||||
|
|----
|
||||||
|
|Drug Allergy
|
||||||
|
|91939003
|
||||||
|
|Sulfonamides
|
||||||
|
|Hives, photosensitivity
|
||||||
|
|04/25/1989
|
||||||
|
|----
|
||||||
|
|}
|
||||||
|
|
||||||
|
{| border="1"|
|
||||||
|
!colspan="5"|Diagnostic Test Results
|
||||||
|
|----
|
||||||
|
!scope="col"|Type
|
||||||
|
!scope="col"|LOINC Code
|
||||||
|
!scope="col"|Test (Normal Range)
|
||||||
|
!scope="col"|Result
|
||||||
|
!scope="col"|Date Performed
|
||||||
|
|----
|
||||||
|
|Chemistry
|
||||||
|
|14771-0
|
||||||
|
|Fasting Blood Glucose (70–100 mg/dl)
|
||||||
|
|145 mg/dl
|
||||||
|
|07/17/2009
|
||||||
|
|----
|
||||||
|
|Hemistry
|
||||||
|
|2823-3
|
||||||
|
|Potassium (3.5–5.3 mg/dl)
|
||||||
|
|4.5 mg/dl
|
||||||
|
|07/17/2009
|
||||||
|
|----
|
||||||
|
|Chemistry
|
||||||
|
|14927-8
|
||||||
|
|Triglycerides (<150 mg/dl)
|
||||||
|
|187 mg/dl
|
||||||
|
|07/17/2009
|
||||||
|
|----
|
||||||
|
|42272-5
|
||||||
|
|Imaging
|
||||||
|
|Chest X-ray, PA & Lateral
|
||||||
|
|The heart outline is normal<br>and the hilar and<br>mediastinal vessels are of<br>normal appearance
|
||||||
|
|07/17/2009
|
||||||
|
|----
|
|
@ -0,0 +1,34 @@
|
||||||
|
Patient Summary Record Test Data – Set #5
|
||||||
|
|
||||||
|
Patient
|
||||||
|
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||||
|
Matthew Brown|09/22/1965 16:48:25|Male|988730987|Medical Record Number|754 Sharp Street<br>Aurora,<br>Colorado 80011<br>303-544-9988
|
||||||
|
|
||||||
|
“Source” for all data for this patient: Pamela Jones, MD
|
||||||
|
|
||||||
|
Problem List
|
||||||
|
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||||
|
Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|07/17/2009
|
||||||
|
Symptom|401.9|Hypertension, Essential|Active|06/05/2008
|
||||||
|
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||||
|
Disorder|44054006|Diabetes Mellitus, Type 2|Active|07/17/2009
|
||||||
|
Disorder|59621000|Essential Hypertension|Active|06/05/2008
|
||||||
|
|
||||||
|
Medication List
|
||||||
|
RxNorm Code
|
||||||
|
|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||||
|
205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|07/17/2009|Active
|
||||||
|
200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|06/05/2008|Active
|
||||||
|
628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|06/05/2008|Active
|
||||||
|
|
||||||
|
Medication Allergy List
|
||||||
|
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||||
|
Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/25/1997
|
||||||
|
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1989
|
||||||
|
|
||||||
|
Diagnostic Test Results
|
||||||
|
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||||
|
Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|145 mg/dl|07/17/2009
|
||||||
|
Hemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.5 mg/dl|07/17/2009
|
||||||
|
Chemistry|14927-8|Triglycerides (<150 mg/dl)|187 mg/dl|07/17/2009
|
||||||
|
42272-5|Imaging|Chest X-ray, PA & Lateral|The heart outline is normal<br>and the hilar and<br>mediastinal vessels are of<br>normal appearance|07/17/2009
|
|
Loading…
Reference in New Issue