VistA-hData/test-patients/NIST-Ambulatory-test-patien...

2.4 KiB
Raw Blame History

1 * indicates alternative standard code per certification criteria
2Patient Summary Record Test Data Set #1
3Patient
4Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
5John D. Smith|07/04/1960 10:15:02|Male|999999999|Medical Record Number|355 Maple Street <br>Williamsport, <br>Pennsylvania 17701 <br>570-837-8364
6“Source” for all data for this patient: John Fitzgerald, MD
7Problem List
8Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
9Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|09/16/2009
10Condition|272.4|Hyperlipidemia|Active|05/05/2002
11Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002
12Symptom|401.9|Hypertension, Essential|Active|05/05/2002
13Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
14Disorder|44054006|Diabetes Mellitus, Type 2|Active|09/16/2009
15Disorder|55822004|Hyperlipidemia|Active|05/05/2002
16Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002
17Disorder|59621000|Essential Hypertension|Active|05/05/2002
18Medication List
19RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
20205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|09/16/2009|Active
21617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|05/05/2002|Active
22200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|05/05/2002|Active
23628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|05/05/2002|Active
24Medication Allergy List
25Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
26Drug Allergy|293597001|Codeine|Hives|06/27/1996
27Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/15/1994
28Diagnostic Test Results
29Type|LOINC Code|Test (Normal Range)|Result|Date Performed
30Chemistry|14771-0|Fasting Blood Glucose (70100 mg/dl)|178 mg/dl|09/16/2009
31Chemistry|14682-9|Creatinine (0.51.4 mg/dl)|1.0 mg/dl|09/16/2009
32Chemistry|14937-7|BUN (730 mg/dl)|18 mg/dl|09/16/2009
33Chemistry|2951-2|Sodium (135146 mg/dl)|141 mg/dl|09/16/2009
34Chemistry|2823-3|Potassium (3.55.3 mg/dl)|4.3 mg/dl|09/16/2009
35Chemistry|14647-2|Total cholesterol (<200 mg/dl)|162 mg/dl|09/16/2009
36Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|43 mg/dl|09/16/2009
37Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|84 mg/dl|09/16/2009
38Chemistry|14927-8|Triglycerides (<150 mg/dl)|177 mg/dl|09/16/2009
39Imaging|24648-8|Chest X-ray, PA|No disease is seen in the<br>lung fields or pleura |09/16/2009