2.5 KiB
2.5 KiB
| 1 | * indicates alternative standard code per certification criteria |
|---|---|
| 2 | Patient Summary Record Test Data – Set #1 |
| 3 | Patient |
| 4 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
| 5 | John D. Smith|07/04/1960|Male|999999999|Medical Record Number|355 Maple Street |
| 6 | 10:15:02|Williamsport, |
| 7 | Pennsylvania|17701 |
| 8 | 570-837-8364 |
| 9 | “Source” for all data for this patient: John Fitzgerald, MD |
| 10 | Problem List |
| 11 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
| 12 | Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|09/16/2009 |
| 13 | Condition|272.4|Hyperlipidemia|Active|05/05/2002 |
| 14 | Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002 |
| 15 | Symptom|401.9|Hypertension, Essential|Active|05/05/2002 |
| 16 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
| 17 | Disorder|44054006|Diabetes Mellitus, Type 2|Active|09/16/2009 |
| 18 | Disorder|55822004|Hyperlipidemia|Active|05/05/2002 |
| 19 | Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002 |
| 20 | Disorder|59621000|Essential Hypertension|Active|05/05/2002 |
| 21 | Medication List |
| 22 | RxNorm |
| 23 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
| 24 | Code |
| 25 | 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|09/16/2009|Active |
| 26 | atorvastatin |
| 27 | 617314|Medication|Lipitor|10 mg|1 Tablet|PO|Q Day|05/05/2002|Active |
| 28 | calcium |
| 29 | RxNorm |
| 30 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
| 31 | Code |
| 32 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|05/05/2002|Active |
| 33 | potassium |
| 34 | 628958|Medication|Klor-Con|10 mEq|1 Tablet|PO|BID|05/05/2002|Active |
| 35 | chloride |
| 36 | Medication Allergy List |
| 37 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
| 38 | Drug Allergy|293597001|Codeine|Hives|06/27/1996 |
| 39 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/15/1994 |
| 40 | Diagnostic Test Results |
| 41 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
| 42 | Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|178 mg/dl|09/16/2009 |
| 43 | Chemistry|14682-9|Creatinine (0.5–1.4 mg/dl)|1.0 mg/dl|09/16/2009 |
| 44 | Chemistry|14937-7|BUN (7–30 mg/dl)|18 mg/dl|09/16/2009 |
| 45 | Chemistry|2951-2|Sodium (135–146 mg/dl)|141 mg/dl|09/16/2009 |
| 46 | Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.3 mg/dl|09/16/2009 |
| 47 | Chemistry|14647-2|Total cholesterol (<200 mg/dl)|162 mg/dl|09/16/2009 |
| 48 | Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|43 mg/dl|09/16/2009 |
| 49 | Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|84 mg/dl|09/16/2009 |
| 50 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|177 mg/dl|09/16/2009 |
| 51 | No disease is seen in the |
| 52 | Imaging|24648-8|Chest X-ray, PA|09/16/2009 |
| 53 | lung fields or pleura |