VistA-hData/test-patients/NIST-Inpatient-test-patient...

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1TD170.306.f.: Exchange clinical information and patient summary record
2* indicates alternative standard code per certification criteria
3Patient Summary Record Test Data Set #1
4Patient
5Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
6Ann 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
8Problem List
9Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
10Diagnosis|428.0|Congestive Heart Failure|Active|02/22/2010
11Diagnosis|410.90|Acute Myocardial Infarction|Resolved|09/16/2007
12Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
13Disorder|42343007|Congestive Heart Failure|Active|02/22/2010
14Disorder|57054005|Acute Myocardial Infarction|Resolved|09/16/2007
15Medication List
16RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
17201372|Medication|captopril|Capoten|25 mg|Tablet|PO|TID|02/25/2010|Active
18200820|Medication|spironolactone|Aldactone|25 mg|Tablet|PO|QID|02/25/2010|Active
19309888|Medication|digoxin|Lanoxin|125 mcg|Tablet|PO|QD|02/25/2010|Active
20628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/25/2010|Active
21198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|09/20/2007|Active
22Medication Allergy List
23Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
24Drug Allergy|293586001|Aspirin|Wheezing|03/02/2007
25Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|04/25/1994
26Diagnostic Test Results
27Type|LOINC Code|Test (Normal Range)|Result|Date Performed
28Imaging|24648-8|Chest X-ray, PA|Enlarged cardiac silhouette, <br>lung fields clear |02/24/2010
29Chemistry|2951-2|Sodium (135146 mg/dl)|138 mg/dl|02/24/2010
30Chemistry|2823-3|Potassium (3.55.3 mg/dl)|4.3 mg/dl|02/24/2010
31Chemistry|2075-0|Chloride (95-107 mEq/L)|98 mEq/L|02/24/2010
32Imaging|24648-8|Chest X-ray, PA|Enlarged cardiac silhouette, <br>horizontal lines in the periphery<br>of lower posterior lung fields |02/22/2010
33Chemistry|2951-2|Sodium (135146 mg/dl)|126 mg/dl|02/22/2010
34Chemistry|2823-3|Potassium (3.55.3 mg/dl)|3.0 mg/dl|02/22/2010
35Chemistry|2075-0|Chloride (95-107 mEq/L)|94 mEq/L|02/22/2010
36Procedure List
37Type|ICD-9 Code|Procedure|Status|Date Performed
38Cardiac|00.66|Percutaneous transluminal coronary angioplasty|Completed|09/17/2007
39Cardiac|37.21|Cardiac catheterization|Completed|10/01/2006
40Type|CPT Code*|Procedure|Status|Date Performed
41Cardiac|92982|Percutaneous transluminal coronary angioplasty|Completed|09/17/2007
42Cardiac|93501|Cardiac catheterization|Completed|10/01/2006