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Patient Summary Record Test Data Set #5
Patient
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
Christine Taylor|09/22/1965 16:48:25|Female|9787478034|Medical Record Number|754 Angel Street Marshalltown Iowa 50158 641-544-9988
“Source” for all data for this patient: Kathryn Thomson, MD
Problem List
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
Diagnosis|540.0|Acute Appendicitis|Resolved|01/09/2010
Diagnosis|434.91|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|03/30/2009
Symptom|401.9|Hypertension, Essential|Chronic|02/25/2008
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
Disorder|74400008|Appendicitis|Resolved|01/09/2010
Disorder|230690007|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
Disorder|44054006|Diabetes Mellitus, Type 2|Active|03/30/2009
Disorder|59621000|Essential Hypertension|Chronic|02/25/2008
Medication List
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active
205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|03/30/2009|Active
209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|03/30/2009|Active
200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|02/25/2008|Active
628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/25/2008|Active
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
884175|Medication|clonidine hydrochloride|Catapres|0.1 mg|1 Tablet|PO|BID|02/25/2008|Active
Medication Allergy List
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
Drug Allergy|293620004|Indomethacin|Rash, dizziness, headache|06/05/2008
Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|05/25/1997
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|08/25/1989
Diagnostic Test Results
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
Chemistry|14771-0|Fasting Blood Glucose (70100 mg/dl)|126 mg/dl|07/15/2010
Chemistry|2823-3|Potassium (3.55.3 mg/dl)|4.3 mg/dl|07/15/2010
Chemistry|14927-8|Triglycerides (<150 mg/dl)|178 mg/dl|07/15/2010
Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance|02/25/2008
Procedure List
Type|ICD-9 Code|Procedure|Status|Date Performed
Surgical|47.09|Emergency Appendectomy|Completed|01/09/2010
Type|CPT Code*|Procedure|Status|Date Performed
Surgical|44950|Emergency Appendectomy|Completed|01/09/2010
1 Patient Summary Record Test Data – Set #5
2 Patient
3 Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
4 Christine Taylor|09/22/1965 16:48:25|Female|9787478034|Medical Record Number|754 Angel Street Marshalltown Iowa 50158 641-544-9988
5 “Source” for all data for this patient: Kathryn Thomson, MD
6 Problem List
7 Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
8 Diagnosis|540.0|Acute Appendicitis|Resolved|01/09/2010
9 Diagnosis|434.91|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
10 Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|03/30/2009
11 Symptom|401.9|Hypertension, Essential|Chronic|02/25/2008
12 Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
13 Disorder|74400008|Appendicitis|Resolved|01/09/2010
14 Disorder|230690007|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
15 Disorder|44054006|Diabetes Mellitus, Type 2|Active|03/30/2009
16 Disorder|59621000|Essential Hypertension|Chronic|02/25/2008
17 Medication List
18 RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
19 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active
20 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|03/30/2009|Active
21 209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|03/30/2009|Active
22 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|02/25/2008|Active
23 628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/25/2008|Active
24
25 RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
26 884175|Medication|clonidine hydrochloride|Catapres|0.1 mg|1 Tablet|PO|BID|02/25/2008|Active
27 Medication Allergy List
28 Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
29 Drug Allergy|293620004|Indomethacin|Rash, dizziness, headache|06/05/2008
30 Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|05/25/1997
31 Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|08/25/1989
32 Diagnostic Test Results
33 Type|LOINC Code|Test (Normal Range)|Result|Date Performed
34 Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|126 mg/dl|07/15/2010
35 Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.3 mg/dl|07/15/2010
36 Chemistry|14927-8|Triglycerides (<150 mg/dl)|178 mg/dl|07/15/2010
37 Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance|02/25/2008
38 Procedure List
39 Type|ICD-9 Code|Procedure|Status|Date Performed
40 Surgical|47.09|Emergency Appendectomy|Completed|01/09/2010
41 Type|CPT Code*|Procedure|Status|Date Performed
42 Surgical|44950|Emergency Appendectomy|Completed|01/09/2010