263 lines
4.0 KiB
Plaintext
263 lines
4.0 KiB
Plaintext
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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{| border="1"|
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!colspan="6"|Patient
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|----
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!scope="col"|Name
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!scope="col"|Date/Time of Birth
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!scope="col"|Gender
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!scope="col"|Identification Number
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!scope="col"|Identification Number Type
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!scope="col"|Address/Phone
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|----
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|Ann Toliver
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|07/16/1950<br>14:15:12
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|Female
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|989285998
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|Medical Record Number
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|353 Wine Street <br>Flint, <br>Michigan 48503 <br> 810-673-8378
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|----
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|}
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“Source” for all data for this patient: Fatima Goyal, MD
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{| border="1"|
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!colspan="6"|Problem List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Diagnosis
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|428.0
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|Congestive Heart Failure
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|Active
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|02/22/2010
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|----
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|Diagnosis
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|410.90
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|Acute Myocardial Infarction
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|Resolved
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|09/16/2007
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|----
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code*
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Disorder
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|42343007
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|Congestive Heart Failure
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|Active
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|02/22/2010
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|----
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|Disorder
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|57054005
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|Acute Myocardial Infarction
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|Resolved
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|09/16/2007
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|----
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|}
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{| border="1"|
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!colspan="10"|Medication List
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|----
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!scope="col"|RxNorm Code
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!scope="col"|Product
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!scope="col"|Generic Name
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!scope="col"|Brand Name
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!scope="col"|Strength
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!scope="col"|Dose
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!scope="col"|Route
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!scope="col"|Frequency
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!scope="col"|Date Started
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!scope="col"|Status
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|----
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|201372
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|Medication
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|captopril
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|Capoten
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|25 mg
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|Tablet
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|PO
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|TID
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|02/25/2010
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|Active
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|----
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|200820
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|Medication
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|spironolactone
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|Aldactone
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|25 mg
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|Tablet
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|PO
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|QID
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|02/25/2010
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|Active
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|----
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|309888
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|Medication
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|digoxin
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|Lanoxin
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|125 mcg
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|Tablet
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|PO
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|QD
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|02/25/2010
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|Active
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|----
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|628958
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|Medication
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|potassium chloride
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|Klor-Con
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|10 mEq
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|1 Tablet
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|PO
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|BID
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|02/25/2010
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|Active
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|----
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|198039
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|Medication
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|nitroglycerin
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|Nitroglycerin
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|400 mcg
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|1 Tablet
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|SL
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|As needed
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|09/20/2007
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|Active
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|----
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|}
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{| border="1"|
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!colspan="5"|Medication Allergy List
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code
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!scope="col"|Medication/Agent
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!scope="col"|Reaction
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!scope="col"|Date Recorded
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|----
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|Drug Allergy
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|293586001
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|Aspirin
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|Wheezing
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|03/02/2007
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|----
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|Drug Allergy
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|294506009
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|Ampicillin
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|Diarrhea, nausea, vomiting
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|04/25/1994
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|----
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|}
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{| border="1"|
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!colspan="5"|Diagnostic Test Results
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|----
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!scope="col"|Type
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!scope="col"|LOINC Code
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!scope="col"|Test (Normal Range)
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!scope="col"|Result
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!scope="col"|Date Performed
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|----
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|Imaging
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|24648-8
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|Chest X-ray, PA
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|Enlarged cardiac silhouette, <br>lung fields clear
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|02/24/2010
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|----
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|Chemistry
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|2951-2
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|Sodium (135–146 mg/dl)
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|138 mg/dl
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|02/24/2010
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|----
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|Chemistry
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|2823-3
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|Potassium (3.5–5.3 mg/dl)
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|4.3 mg/dl
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|02/24/2010
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|----
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|Chemistry
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|2075-0
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|Chloride (95-107 mEq/L)
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|98 mEq/L
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|02/24/2010
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|----
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|Imaging
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|24648-8
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|Chest X-ray, PA
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|Enlarged cardiac silhouette, <br>horizontal lines in the periphery<br>of lower posterior lung fields
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|02/22/2010
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|----
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|Chemistry
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|2951-2
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|Sodium (135–146 mg/dl)
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|126 mg/dl
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|02/22/2010
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|----
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|Chemistry
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|2823-3
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|Potassium (3.5–5.3 mg/dl)
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|3.0 mg/dl
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|02/22/2010
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|----
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|Chemistry
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|2075-0
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|Chloride (95-107 mEq/L)
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|94 mEq/L
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|02/22/2010
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|----
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|}
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{| border="1"|
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!colspan="5"|Procedure List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Procedure
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!scope="col"|Status
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!scope="col"|Date Performed
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|----
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|Cardiac
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|00.66
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|Percutaneous transluminal coronary angioplasty
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|Completed
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|09/17/2007
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|----
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|Cardiac
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|37.21
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|Cardiac catheterization
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|Completed
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|10/01/2006
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|----
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|----
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!scope="col"|Type
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!scope="col"|CPT Code*
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!scope="col"|Procedure
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!scope="col"|Status
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!scope="col"|Date Performed
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|----
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|Cardiac
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|92982
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|Percutaneous transluminal coronary angioplasty
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|Completed
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|09/17/2007
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|----
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|Cardiac
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|93501
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|Cardiac catheterization
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|Completed
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|10/01/2006
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|----
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