1.9 KiB
1.9 KiB
1 | Patient Summary Record Test Data – Set #3 |
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2 | Patient |
3 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
4 | Jane Andrews|05/12/1955|Female|9639275266|Medical Record Number|355 1st Street |
5 | 09:30:15|Fargo, |
6 | North Dakota|54102 |
7 | 701-366-8364 |
8 | “Source” for all data for this patient: Robert James, MD |
9 | Problem List |
10 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
11 | Diagnosis|486|Pneumonia|Resolved|01/22/2010 |
12 | Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|10/10/1999 |
13 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
14 | Disorder|233604007|Pneumonia|Resolved|01/22/2010 |
15 | Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|10/10/1999 |
16 | Medication List |
17 | RxNorm |
18 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
19 | Code |
20 | 308460|Medication|azithromycin|Azithromycin|250 mg|1 Tablet|PO|QD|01/22/2010|No Longer |
21 | RxNorm |
22 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
23 | Code |
24 | 836370|Medication|ipratropium|Atrovent|18|2 Puffs|Inhaled|QID|10/10/1999|Active |
25 | bromide|Inhaler|mcg/puff |
26 | monhydrate |
27 | 630208|Medication|Albuterol|2.5|2 Puffs|Inhaled|Q 4 PRN|10/10/1999|Active |
28 | albuterol sulfate |
29 | Inhaler|mg/3ml |
30 | Medication Allergy List |
31 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
32 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|06/10/2009 |
33 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988 |
34 | Diagnostic Test Results |
35 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
36 | Hyperinflated lungs with |
37 | 42272-5|flattened diaphragm and |
38 | Imaging|Chest X-ray, PA & Lateral|02/15/2010 |
39 | central pulmonary artery |
40 | enlargement |
41 | Hemoglobin (male: 14-18 g/dl |
42 | Hematology|718-7|16 g/dl|12/22/2009 |
43 | female: 12-16 g/dl) |
44 | Hematocrit (male: 40-54% |
45 | Hematology|4544-3|45%|12/22/2009 |
46 | female: 36-48%) |
47 | Cardiology|34534-8|Electrocardiogram|Normal Sinus Rhythm|12/22/2009 |