246 lines
3.6 KiB
Plaintext
246 lines
3.6 KiB
Plaintext
* indicates alternative standard code per certification criteria
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Patient Summary Record Test Data – Set #1
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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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|John D. Smith
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|07/04/1960 10:15:02
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|Male
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|999999999
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|Medical Record Number
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|355 Maple Street <br>Williamsport, <br>Pennsylvania 17701 <br>570-837-8364
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|----
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|}
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“Source” for all data for this patient: John Fitzgerald, 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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|250.02
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|Diabetes Mellitus, Type 2
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|Active
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|09/16/2009
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|----
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|Condition
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|272.4
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|Hyperlipidemia
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|Active
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|05/05/2002
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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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|----
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|Symptom
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|401.9
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|Hypertension, Essential
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|Active
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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"|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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|44054006
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|Diabetes Mellitus, Type 2
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|Active
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|09/16/2009
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|----
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|Disorder
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|55822004
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|Hyperlipidemia
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|Active
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|05/05/2002
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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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|Disorder
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|59621000
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|Essential Hypertension
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|Active
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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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|----
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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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|205875
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|Medication
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|glyburide
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|Diabeta
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|2.5 mg
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|1 Tablet
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|PO
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|Q AM
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|09/16/2009
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|Active
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|----
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|617314
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|Medication
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|atorvastatin calcium
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|Lipitor
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|10 mg
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|1 Tablet
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|PO
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|Q Day
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|05/05/2002
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|Active
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|----
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|200801
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|Medication
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|furosemide
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|Lasix
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|20 mg
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|1 Tablet
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|PO
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|BID
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|05/05/2002
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|Active
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|----
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|628958
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|Medication
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|potassium chloride
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|Klor-Con
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|10 mEq
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|1 Tablet
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|PO
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|BID
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|05/05/2002
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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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|----
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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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|293597001
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|Codeine
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|Hives
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|06/27/1996
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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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|03/15/1994
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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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|----
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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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|Chemistry
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|14771-0
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|Fasting Blood Glucose (70–100 mg/dl)
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|178 mg/dl
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|09/16/2009
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|----
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|Chemistry
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|14682-9
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|Creatinine (0.5–1.4 mg/dl)
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|1.0 mg/dl
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|09/16/2009
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|----
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|Chemistry
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|14937-7
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|BUN (7–30 mg/dl)
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|18 mg/dl
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|09/16/2009
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|----
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|Chemistry
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|2951-2
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|Sodium (135–146 mg/dl)
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|141 mg/dl
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|09/16/2009
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|----
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|Chemistry
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|2823-3
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|Potassium (3.5–5.3 mg/dl)
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|4.3 mg/dl
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|09/16/2009
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|----
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|Chemistry
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|14647-2
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|Total cholesterol (<200 mg/dl)
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|162 mg/dl
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|09/16/2009
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|----
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|Chemistry
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|14646-4
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|HDL cholesterol (?40 mg/dl)
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|43 mg/dl
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|09/16/2009
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|----
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|Chemistry
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|2089-1
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|LDL cholesterol (<100 mg/dl)
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|84 mg/dl
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|09/16/2009
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|----
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|Chemistry
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|14927-8
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|Triglycerides (<150 mg/dl)
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|177 mg/dl
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|09/16/2009
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|----
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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 the<br>lung fields or pleura
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|09/16/2009
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|----
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|}
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