230 lines
3.6 KiB
Plaintext
230 lines
3.6 KiB
Plaintext
Patient Summary Record Test Data – Set #3
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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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|Lorraine Blevins
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|04/16/1957<br>20:15:35
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|Female
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|967385998
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|Medical Record Number
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|1020 Stuart Street<br>Morton, <br>Illinois 61550<br> 309-374-8938
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|----
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|}
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“Source” for all data for this patient: Louis Randolph, 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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|715.35
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|Right hip osteoarthritis
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|Resolved
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|02/12/2010
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|----
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|Finding
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|414.01
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|Coronary Artery Disease (CAD)
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|Chronic
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|05/05/2002
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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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|239872002
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|Right hip osteoarthritis
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|Resolved
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|02/12/2010
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|----
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|Disorder
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|53741008
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|Coronary Arteriosclerosis
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|Chronic
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|05/05/2002
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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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!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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|855320
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|Medication
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|warfarin
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|Coumadin
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|3 mg
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|1 Tablet
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|PO
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|QD
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|02/15/2010
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|Active
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|209613
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|Medication
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|bisacodyl
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|Dulcolax
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|5 mg
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|1 Tablet
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|PO
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|QD
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|02/15/2010
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|Active
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|309362
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|Medication
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|clopidogrel
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|Plavix
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|75 mg
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|1 Tablet
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|PO
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|QD
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|05/15/2002
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|Active
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|----
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|197361
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|Medication
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|amlodipine
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|Norvasc
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|5 mg
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|1 Tablet
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|PO
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|QD
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|07/15/2009
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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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!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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|91939003
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|Sulfonamides
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|Hives, photosensitivity
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|06/06/1998
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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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!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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|37721-8
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|X-ray, 2 views, Right Hip
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|Subchondral sclerosis,<br> increased density in<br>subchondral bone
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|02/12/2010
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|Imaging
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|24648-8
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|Chest X-ray, PA
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|No disease is seen in<br> the lung fields or pleura
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|06/05/2009
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|Hematology
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|718-7
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|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)
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|11.2 g/dl
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|06/05/2009
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|Hematology
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|4544-3
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|Hematocrit (male: 40-54% <br>female: 36-48%)
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|34%
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|06/05/2009
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|----
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|Coagulation
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|34714-6
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|Prothrombin Time/ International Normalized Ratio (PT/INR)<br>(2.5 – 3.5)
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|3.1
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|06/05/2009
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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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|Surgical
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|81.51
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|Total Hip Replacement, Right
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|Completed
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|02/14/2010
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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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|05/05/2002
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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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|Surgical
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|27130
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|Total Hip Replacement, Right
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|Completed
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|02/14/2010
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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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|05/05/2002
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|----
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