60 lines
5.8 KiB
Plaintext
60 lines
5.8 KiB
Plaintext
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 |