2.6 KiB
2.6 KiB
1 | TD170.306.f.: Exchange clinical information and patient summary record |
---|---|
2 | * indicates alternative standard code per certification criteria |
3 | Patient Summary Record Test Data – Set #1 |
4 | Patient |
5 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
6 | Ann Toliver|07/16/1950<br>14:15:12|Female|989285998|Medical Record Number|353 Wine Street <br>Flint, <br>Michigan 48503 <br> 810-673-8378 |
7 | “Source” for all data for this patient: Fatima Goyal, MD |
8 | Problem List |
9 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
10 | Diagnosis|428.0|Congestive Heart Failure|Active|02/22/2010 |
11 | Diagnosis|410.90|Acute Myocardial Infarction|Resolved|09/16/2007 |
12 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
13 | Disorder|42343007|Congestive Heart Failure|Active|02/22/2010 |
14 | Disorder|57054005|Acute Myocardial Infarction|Resolved|09/16/2007 |
15 | Medication List |
16 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
17 | 201372|Medication|captopril|Capoten|25 mg|Tablet|PO|TID|02/25/2010|Active |
18 | 200820|Medication|spironolactone|Aldactone|25 mg|Tablet|PO|QID|02/25/2010|Active 309888|Medication|digoxin|Lanoxin|125 mcg|Tablet|PO|QD|02/25/2010|Active |
19 | 628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/25/2010|Active |
20 | 198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|09/20/2007|Active |
21 | Medication Allergy List |
22 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
23 | Drug Allergy|293586001|Aspirin|Wheezing|03/02/2007 |
24 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|04/25/1994 |
25 | Diagnostic Test Results |
26 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
27 | Imaging|24648-8|Chest X-ray, PA|Enlarged cardiac silhouette, <br>lung fields clear |02/24/2010 |
28 | Chemistry|2951-2|Sodium (135–146 mg/dl)|138 mg/dl|02/24/2010 |
29 | Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.3 mg/dl|02/24/2010 |
30 | Chemistry|2075-0|Chloride (95-107 mEq/L)|98 mEq/L|02/24/2010 |
31 | Imaging|24648-8|Chest X-ray, PA|Enlarged cardiac silhouette, <br>horizontal lines in the periphery<br>of lower posterior lung fields |02/22/2010 |
32 | Chemistry|2951-2|Sodium (135–146 mg/dl)|126 mg/dl|02/22/2010 |
33 | Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|3.0 mg/dl|02/22/2010 |
34 | Chemistry|2075-0|Chloride (95-107 mEq/L)|94 mEq/L|02/22/2010 |
35 | Procedure List |
36 | Type|ICD-9 Code|Procedure|Status|Date Performed |
37 | Cardiac|00.66|Percutaneous transluminal coronary angioplasty|Completed|09/17/2007 |
38 | Cardiac|37.21|Cardiac catheterization|Completed|10/01/2006 |
39 | Type|CPT Code*|Procedure|Status|Date Performed |
40 | Cardiac|92982|Percutaneous transluminal coronary angioplasty|Completed|09/17/2007 |
41 | Cardiac|93501|Cardiac catheterization|Completed|10/01/2006 |