2.3 KiB
2.3 KiB
| 1 | Patient Summary Record Test Data – Set #3 |
|---|---|
| 2 | Patient |
| 3 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
| 4 | Lorraine Blevins|04/16/1957<br>20:15:35|Female|967385998|Medical Record Number|1020 Stuart Street<br>Morton, <br>Illinois 61550<br> 309-374-8938 |
| 5 | “Source” for all data for this patient: Louis Randolph, MD |
| 6 | Problem List |
| 7 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
| 8 | Diagnosis|715.35|Right hip osteoarthritis|Resolved|02/12/2010 |
| 9 | Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002 |
| 10 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
| 11 | Disorder|239872002|Right hip osteoarthritis|Resolved|02/12/2010 |
| 12 | Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002 |
| 13 | Medication List |
| 14 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
| 15 | 855320|Medication|warfarin|Coumadin|3 mg|1 Tablet|PO|QD|02/15/2010|Active |
| 16 | 209613|Medication|bisacodyl|Dulcolax|5 mg|1 Tablet|PO|QD|02/15/2010|Active |
| 17 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|05/15/2002|Active |
| 18 | 197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active |
| 19 | Medication Allergy List |
| 20 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
| 21 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|06/06/1998 |
| 22 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|04/25/1994 |
| 23 | Diagnostic Test Results |
| 24 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
| 25 | Imaging|37721-8|X-ray, 2 views, Right Hip|Subchondral sclerosis,<br> increased density in<br>subchondral bone|02/12/2010 |
| 26 | Imaging|24648-8|Chest X-ray, PA|No disease is seen in<br> the lung fields or pleura|06/05/2009 |
| 27 | Hematology|718-7|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)|11.2 g/dl|06/05/2009 |
| 28 | Hematology|4544-3|Hematocrit (male: 40-54% <br>female: 36-48%)|34%|06/05/2009 |
| 29 | Coagulation|34714-6|Prothrombin Time/ International Normalized Ratio (PT/INR)<br>(2.5 – 3.5) |3.1|06/05/2009 |
| 30 | Procedure List |
| 31 | Type|ICD-9 Code|Procedure|Status|Date Performed |
| 32 | Surgical|81.51|Total Hip Replacement, Right|Completed|02/14/2010 |
| 33 | Cardiac|37.21|Cardiac catheterization|Completed|05/05/2002 |
| 34 | Type|CPT Code*|Procedure|Status|Date Performed |
| 35 | Surgical|27130|Total Hip Replacement, Right|Completed|02/14/2010 |
| 36 | Cardiac|93501|Cardiac catheterization|Completed|05/05/2002 |