text form of test patients from NIST MU test scripts
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TD170.306.f.: Exchange clinical information and patient summary record
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* indicates alternative standard code per certification criteria
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Patient Summary Record Test Data – 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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Ann Toliver 07/16/1950 Female 989285998 Medical Record Number 353 Wine Street
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14:15:12 Flint,
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Michigan 48503
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810-673-8378
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“Source” for all data for this patient: Fatima Goyal, 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 428.0 Congestive Heart Failure Active 02/22/2010
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Diagnosis 410.90 Acute Myocardial Infarction Resolved 09/16/2007
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Type SNOMED Code* Patient Problem Status Date Diagnosed
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Disorder 42343007 Congestive Heart Failure Active 02/22/2010
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Disorder 57054005 Acute Myocardial Infarction Resolved 09/16/2007
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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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201372 Medication captopril Capoten 25 mg Tablet PO TID 02/25/2010 Active
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200820 Medication spironolactone Aldactone 25 mg Tablet PO QID 02/25/2010 Active
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309888 Medication digoxin Lanoxin 125 mcg Tablet PO QD 02/25/2010 Active
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potassium
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628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 02/25/2010 Active
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chloride
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198039 Medication nitroglycerin Nitroglycerin 400 mcg 1 Tablet SL As needed 09/20/2007 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 293586001 Aspirin Wheezing 03/02/2007
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Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 04/25/1994
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Diagnostic Test Results
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Type LOINC Code Test (Normal Range) Result Date Performed
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Enlarged cardiac silhouette,
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Imaging 24648-8 Chest X-ray, PA 02/24/2010
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lung fields clear
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Chemistry 2951-2 Sodium (135–146 mg/dl) 138 mg/dl 02/24/2010
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Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.3 mg/dl 02/24/2010
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Chemistry 2075-0 Chloride (95-107 mEq/L) 98 mEq/L 02/24/2010
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Enlarged cardiac silhouette,
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Imaging 24648-8 Chest X-ray, PA horizontal lines in the periphery 02/22/2010
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of lower posterior lung fields
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Chemistry 2951-2 Sodium (135–146 mg/dl) 126 mg/dl 02/22/2010
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Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 3.0 mg/dl 02/22/2010
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Chemistry 2075-0 Chloride (95-107 mEq/L) 94 mEq/L 02/22/2010
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Procedure List
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Type ICD-9 Code Procedure Status Date Performed
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Cardiac 00.66 Percutaneous transluminal coronary angioplasty Completed 09/17/2007
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Cardiac 37.21 Cardiac catheterization Completed 10/01/2006
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Type CPT Code* Procedure Status Date Performed
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Cardiac 92982 Percutaneous transluminal coronary angioplasty Completed 09/17/2007
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Cardiac 93501 Cardiac catheterization Completed 10/01/2006
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Patient Summary Record Test Data – Set #2
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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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Ruth Warholde 05/20/1954 Female 9836469798 Medical Record Number 225 Park Street
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23:59:45 Morton,
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“Source” for all data for this patient: Jackson Shoals, 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 780.2 Syncope and collapse, vasovagal attack Active 02/15/2010
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Diagnosis 434.91 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
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Diagnosis 599.0 Urinary tract infection Recurrent 09/22/2008
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Diagnosis 496.0 Chronic Obstructive Pulmonary Disease Chronic 08/12/2007
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Symptom 401.9 Hypertension, essential Chronic 05/16/2006
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Type SNOMED Code* Patient Problem Status Date Diagnosed
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Disorder 398665005 Vasovagal syncope Active 02/15/2010
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Disorder 230690007 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
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Disorder 197927001 Recurrent urinary tract infection Recurrent 09/22/2008
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Disorder 13645005 Chronic Obstructive Lung Disease Chronic 08/12/2007
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Disorder 59621000 Essential Hypertension Chronic 05/16/2006
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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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209834 Medication docusate Colace 100 mg 1 Capsule PO BID 02/16/2010 Active
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205326 Medication lisinopril Zestril 30 mg 1 Tablet PO QD 07/15/2009 Active
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309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/15/2009 Active
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197361 Medication amlodipine Norvasc 5 mg 1 Tablet PO QD 07/15/2009 Active
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No Longer
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539712 Medication nitrofurantoin Macrobid 100 mg 1 Capsule PO QD 09/22/2008
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Active
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ipratropium
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Atrovent 18 By oral
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836370 Medication bromide 2 puffs QID 08/14/2007 Active
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inhaler mcg/puff inhalation
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monhydrate
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clonidine
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884175 Medication Catapres 0.1 mg 1 Tablet PO BID 05/16/2006 Active
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hydrochloride
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Medication Allergy List
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Type SNOMED Code Medication/Agent Reaction Date Recorded
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Nausea, vomiting, rash,
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Drug Allergy 293620004 Indomethacin 03/25/2003
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dizziness, headache
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Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 07/26/1999
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Diagnostic Test Results
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Type LOINC Code Test (Normal Range) Result Date Performed
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Small high right occipital lobe
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contusion. No evidence of
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Imaging 11539-4 CT, head 02/24/2010
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extra-axial blood. Significant
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sinus disease.
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Hematology 718-7 Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) 13 g/dl 02/17/2010
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Hematology 4544-3 Hematocrit (male: 40-54% female: 36-48%) 38% 02/17/2010
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Chemistry 2951-2 Sodium (135–146 mg/dl) 136 mg/dl 02/17/2010
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Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 3.9 mg/dl 02/17/2010
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Imaging 34534-8 Electrocardiogram Normal Sinus Rhythm 02/15/2010
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Urine culture, routine
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Microbiology 630-4 Negative: No growth 10/02/2008
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(Negative: No growth Positive: >10,000 CFU/ml)
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Procedure List
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Type ICD-9 Code Procedure Status Date Performed
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Surgical 66.39 Bilateral tubal ligation Completed 06/14/1990
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Type CPT Code* Procedure Status Date Performed
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Surgical 58600 Bilateral tubal ligation
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Patient Summary Record Test Data – Set #3
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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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Lorraine 04/16/1957 Female 967385998 Medical Record Number 1020 Stuart Street
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Blevins 20:15:35 Morton,
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“Source” for all data for this patient: Louis Randolph, 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 715.35 Right hip osteoarthritis Resolved 02/12/2010
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Finding 414.01 Coronary Artery Disease (CAD) Chronic 05/05/2002
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Type SNOMED Code* Patient Problem Status Date Diagnosed
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Disorder 239872002 Right hip osteoarthritis Resolved 02/12/2010
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Disorder 53741008 Coronary Arteriosclerosis Chronic 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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855320 Medication warfarin Coumadin 3 mg 1 Tablet PO QD 02/15/2010 Active
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209613 Medication bisacodyl Dulcolax 5 mg 1 Tablet PO QD 02/15/2010 Active
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309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 05/15/2002 Active
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197361 Medication amlodipine Norvasc 5 mg 1 Tablet PO QD 07/15/2009 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 91939003 Sulfonamides Hives, photosensitivity 06/06/1998
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Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 04/25/1994
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Diagnostic Test Results
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Type LOINC Code Test (Normal Range) Result Date Performed
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Subchondral sclerosis,
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37721-8
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Imaging X-ray, 2 views, Right Hip increased density in 02/12/2010
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subchondral bone
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No disease is seen in the lung
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Imaging 24648-8 Chest X-ray, PA 06/05/2009
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fields or pleura
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Hemoglobin (male: 14-18 g/dl
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Hematology 718-7 11.2 g/dl 06/05/2009
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female: 12-16 g/dl)
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Hematocrit (male: 40-54%
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Hematology 4544-3 34% 06/05/2009
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female: 36-48%)
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Type LOINC Code Test (Normal Range) Result Date Performed
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Prothrombin Time/ International Normalized Ratio (PT/INR)
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Coagulation 34714-6 3.1 06/05/2009
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(2.5 – 3.5)
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Procedure List
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Type ICD-9 Code Procedure Status Date Performed
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Surgical 81.51 Total Hip Replacement, Right Completed 02/14/2010
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Cardiac 37.21 Cardiac catheterization Completed 05/05/2002
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Type CPT Code* Procedure Status Date Performed
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Surgical 27130 Total Hip Replacement, Right Completed 02/14/2010
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Cardiac 93501 Cardiac catheterization Completed 05/05/2002
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Patient Summary Record Test Data – Set #4
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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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Paul Jackson 03/08/1962 Male 998777349 Medical Record Number 754 Samuel Street,
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14:25:50 Blanchard,
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Oklahoma 73010
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405-228-9292
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“Source” for all data for this patient: Mary Pfiffer, 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 410.90 Acute Myocardial Infarction Resolved 07/12/2010
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Finding 414.01 Coronary Artery Disease (CAD) Chronic 07/05/2000
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Type SNOMED Code* Patient Problem Status Date Diagnosed
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Disorder 57054005 Acute Myocardial Infarction Resolved 07/12/2010
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Disorder 53741008 Coronary Arteriosclerosis Chronic 07/05/2000
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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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198039 Medication nitroglycerin Nitroglycerin 400 mcg 1 Tablet SL As needed 07/15/2010 Active
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309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/05/2000 Active
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197361 Medication amlodipine Norvasc 5 mg 1 Tablet PO QD 07/05/2000 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 07/12/2010
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Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/28/2000
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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 14647-2 Total cholesterol (<200 mg/dl) 220 mg/dl 07/15/2010
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Chemistry 14927-8 Triglycerides (<150 mg/dl) 165 mg/dl 07/15/2010
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The heart outline is slightly
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enlarged, the hilar and
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Imaging 42272-5 Chest X-ray, PA & Lateral 07/15/2010
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mediastinal vessels are of
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normal appearance
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Hematology 718-7 Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) 12.8 g/dl 2/18/2010
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Hematology 4544-3 Hematocrit (male: 40-54% female: 36-48%) 44% 2/18/2010
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Procedure List
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Type ICD-9 Code Procedure Status Date Performed
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Cardiac 00.66 Percutaneous transluminal coronary Completed 07/15/2010
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angioplasty
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Type CPT Code* Procedure Status Date Performed
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Cardiac 92982 Percutaneous transluminal coronary Completed 07/15/2010
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angioplasty
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Patient Summary Record Test Data – Set #5
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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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Christine Taylor 09/22/1965 Female 9787478034 Medical Record Number 754 Angel Street
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16:48:25 Marshalltown
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Iowa 50158
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641-544-9988
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“Source” for all data for this patient: Kathryn Thomson, 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 540.0 Acute Appendicitis Resolved 01/09/2010
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Diagnosis 434.91 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
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Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 03/30/2009
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Symptom 401.9 Hypertension, Essential Chronic 02/25/2008
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Type SNOMED Code* Patient Problem Status Date Diagnosed
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Disorder 74400008 Appendicitis Resolved 01/09/2010
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Disorder 230690007 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
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Disorder 44054006 Diabetes Mellitus, Type 2 Active 03/30/2009
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Disorder 59621000 Essential Hypertension Chronic 02/25/2008
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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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309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/15/2009 Active
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205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 03/30/2009 Active
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209834 Medication docusate Colace 100 mg 1 Capsule PO BID 03/30/2009 Active
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200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 02/25/2008 Active
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potassium
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628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 02/25/2008 Active
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chloride
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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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clonidine
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884175 Medication Catapres 0.1 mg 1 Tablet PO BID 02/25/2008 Active
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hydrochloride
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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 293620004 Indomethacin Rash, dizziness, headache 06/05/2008
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Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 05/25/1997
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Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 08/25/1989
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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 (70–100 mg/dl) 126 mg/dl 07/15/2010
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Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.3 mg/dl 07/15/2010
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Chemistry 14927-8 Triglycerides (<150 mg/dl) 178 mg/dl 07/15/2010
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The heart outline is normal
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42272-5 and the hilar and
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Imaging Chest X-ray, PA & Lateral mediastinal vessels are of 02/25/2008
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normal appearance
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Procedure List
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Type ICD-9 Code Procedure Status Date Performed
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Surgical 47.09 Emergency Appendectomy Completed 01/09/2010
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Type CPT Code* Procedure Status Date Performed
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Surgical 44950 Emergency Appendectomy Completed 01/09/2010
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* indicates alternative standard code per certification criteria
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Patient Summary Record Test Data – 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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“Source” 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 (70–100 mg/dl) 178 mg/dl 09/16/2009
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Chemistry 14682-9 Creatinine (0.5–1.4 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 (135–146 mg/dl) 141 mg/dl 09/16/2009
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Chemistry 2823-3 Potassium (3.5–5.3 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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Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary Record
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APPROVED (Pending) Version 1.0 July 21, 2010
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Patient Summary Record Test Data – Set #2
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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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Ralph Johnson 06/28/1984 Male 9813466798 Medical Record Number 355 Elm Street
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13:20:10 Morton,
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Illinois 61550
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309-377-8365
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“Source” for all data for this patient: Carl Roberts, 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 493.00 Asthma, unspecified Active 12/22/2009
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Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 08/10/2008
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Type SNOMED Code* Patient Problem Status Date Diagnosed
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Disorder 195967001 Asthma Active 12/22/2009
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Disorder 44054006 Diabetes Mellitus, Type 2 Active 08/10/2008
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Medication List
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RxNorm
|
||||
Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
||||
Code
|
||||
Alupent
|
||||
metaproterenol
|
||||
206833 Medication Inhalation 15 mg/ml 2 Puffs Inhaled Q4h 12/22/2009 Active
|
||||
sulfate
|
||||
Aerosol
|
||||
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
|
||||
Nausea, vomiting, rash,
|
||||
Drug Allergy 293620004 Indomethacin 03/25/2003
|
||||
dizziness, headache
|
||||
Diagnostic Test Results
|
||||
Type LOINC Code Test (Normal Range) Result Date Performed
|
||||
Increased bronchial wall
|
||||
Imaging 24648-8 Chest X-ray, PA 02/16/2010
|
||||
markings, patchy infiltrates
|
||||
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 +1,55 @@
|
|||
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 Female 9639275266 Medical Record Number 355 1st Street
|
||||
09:30:15 Fargo,
|
||||
North Dakota 54102
|
||||
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
|
||||
Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
||||
Code
|
||||
308460 Medication azithromycin Azithromycin 250 mg 1 Tablet PO QD 01/22/2010 No Longer
|
||||
|
||||
RxNorm
|
||||
Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
||||
Code
|
||||
836370 Medication ipratropium Atrovent 18 2 Puffs Inhaled QID 10/10/1999 Active
|
||||
bromide Inhaler mcg/puff
|
||||
monhydrate
|
||||
630208 Medication Albuterol 2.5 2 Puffs Inhaled Q 4 PRN 10/10/1999 Active
|
||||
albuterol sulfate
|
||||
Inhaler mg/3ml
|
||||
|
||||
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
|
||||
Hyperinflated lungs with
|
||||
42272-5 flattened diaphragm and
|
||||
Imaging Chest X-ray, PA & Lateral 02/15/2010
|
||||
central pulmonary artery
|
||||
enlargement
|
||||
Hemoglobin (male: 14-18 g/dl
|
||||
Hematology 718-7 16 g/dl 12/22/2009
|
||||
female: 12-16 g/dl)
|
||||
Hematocrit (male: 40-54%
|
||||
Hematology 4544-3 45% 12/22/2009
|
||||
female: 36-48%)
|
||||
Cardiology 34534-8 Electrocardiogram Normal Sinus Rhythm 12/22/2009
|
||||
|
|
@ -0,0 +1,52 @@
|
|||
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 Female 998877799 Medical Record Number 754 Samuel Street,
|
||||
Shawville,
|
||||
18:25:59
|
||||
“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
|
||||
Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
||||
Code
|
||||
atorvastatin
|
||||
617314 Medication Lipitor 10 mg 1 Tablet PO Q Day 07/05/2006 Active
|
||||
calcium
|
||||
200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 07/05/2006 Active
|
||||
(potassium
|
||||
628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 07/05/2006 Active
|
||||
chloride
|
||||
|
||||
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
|
||||
|
||||
Type LOINC Code Test (Normal Range) Result Date Performed
|
||||
Imaging 42272-5 The heart outline is normal 07/15/2009
|
||||
Chest X-ray, PA & Lateral and the hilar and
|
||||
|
||||
|
||||
|
|
@ -0,0 +1,46 @@
|
|||
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 Male 988730987 Medical Record Number 754 Sharp Street
|
||||
16:48:25 Aurora,
|
||||
Colorado 80011
|
||||
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
|
||||
Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
||||
Code
|
||||
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
|
||||
potassium
|
||||
628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 06/05/2008 Active
|
||||
chloride
|
||||
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
|
||||
|
||||
The heart outline is normal
|
||||
42272-5 and the hilar and
|
||||
Imaging Chest X-ray, PA & Lateral mediastinal vessels are of 07/17/2009
|
||||
|
||||
normal appearance
|
||||
Loading…
Reference in New Issue