2.4 KiB
2.4 KiB
1 | * indicates alternative standard code per certification criteria |
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2 | Patient Summary Record Test Data – Set #1 |
3 | Patient |
4 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
5 | John 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 |
7 | Problem List |
8 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
9 | Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|09/16/2009 |
10 | Condition|272.4|Hyperlipidemia|Active|05/05/2002 |
11 | Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002 |
12 | Symptom|401.9|Hypertension, Essential|Active|05/05/2002 |
13 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
14 | Disorder|44054006|Diabetes Mellitus, Type 2|Active|09/16/2009 |
15 | Disorder|55822004|Hyperlipidemia|Active|05/05/2002 |
16 | Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002 |
17 | Disorder|59621000|Essential Hypertension|Active|05/05/2002 |
18 | Medication List |
19 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
20 | 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|09/16/2009|Active |
21 | 617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|05/05/2002|Active |
22 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|05/05/2002|Active |
23 | 628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|05/05/2002|Active |
24 | Medication Allergy List |
25 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
26 | Drug Allergy|293597001|Codeine|Hives|06/27/1996 |
27 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/15/1994 |
28 | Diagnostic Test Results |
29 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
30 | Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|178 mg/dl|09/16/2009 |
31 | Chemistry|14682-9|Creatinine (0.5–1.4 mg/dl)|1.0 mg/dl|09/16/2009 |
32 | Chemistry|14937-7|BUN (7–30 mg/dl)|18 mg/dl|09/16/2009 |
33 | Chemistry|2951-2|Sodium (135–146 mg/dl)|141 mg/dl|09/16/2009 |
34 | Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.3 mg/dl|09/16/2009 |
35 | Chemistry|14647-2|Total cholesterol (<200 mg/dl)|162 mg/dl|09/16/2009 |
36 | Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|43 mg/dl|09/16/2009 |
37 | Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|84 mg/dl|09/16/2009 |
38 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|177 mg/dl|09/16/2009 |
39 | Imaging|24648-8|Chest X-ray, PA|No disease is seen in the<br>lung fields or pleura |09/16/2009 |