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