Difference between revisions of "NIST-EP-Patient-3-Visit-2"
From VistApedia
DaveMishler (talk | contribs) (initial data entry) |
(Added glossary link to Record~) |
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| Line 22: | Line 22: | ||
|Female | |Female | ||
|9688675266 | |9688675266 | ||
| − | |Medical Record Number | + | |Medical [[Record~|Record]] Number |
|996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534 | |996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534 | ||
|---- | |---- | ||
| Line 98: | Line 98: | ||
{| border="1"| | {| border="1"| | ||
| − | !colspan="5"|Medication Allergy List | + | !colspan="5"|Medication [[Allergy~|Allergy]] List |
|---- | |---- | ||
!scope="col"|Type | !scope="col"|Type | ||
| Line 104: | Line 104: | ||
!scope="col"|Medication/Agent | !scope="col"|Medication/Agent | ||
!scope="col"|Reaction | !scope="col"|Reaction | ||
| − | !scope="col"|Date | + | !scope="col"|Date [[Record~|Record]]ed |
|---- | |---- | ||
| − | |Drug Allergy | + | |Drug [[Allergy~|Allergy]] |
|91936005 | |91936005 | ||
|Penicillin | |Penicillin | ||
| Line 112: | Line 112: | ||
|06/10/2009 | |06/10/2009 | ||
|---- | |---- | ||
| − | |Drug Allergy | + | |Drug [[Allergy~|Allergy]] |
|91939003 | |91939003 | ||
|Sulfonamides | |Sulfonamides | ||
Latest revision as of 12:58, 7 April 2012
Test Procedure for §170.304.h Clinical Summaries APPROVED (Pending) Version 1.0 July 21, 2010
TD170.304.h.: Clinical summaries
- indicates alternative standard code per certification criteria
Clinical Summaries Test Data – Set #3|Office Visit #2 for Barbara Simpson
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Barbara Simpson | 10/12/1956 19:47:01 | Female | 9688675266 | Medical Record Number | 996 Dalton Street, Fargo, North Dakota 54102 701-366-5534 |
“Source” for all data for this patient: Robert James, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Diagnosis | 496.0 | Chronic Obstructive Pulmonary Disease | Chronic | 02/10/2010 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 13645005 | Chronic Obstructive Lung Disease | Chronic | 02/10/2010 | |
| Medication List | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
| 836370 | Medication | ipratropium bromide monohydrate | Atrovent Inhaler | 18 mcg/puff | 2 Puffs | Inhaled | QID | 02/10/2010 | Active |
| 630208 | Medication | albuterol sulfate | Albuterol Inhaler | 2.5 mg/3ml | 2 Puffs | Inhaled | Q 4 hours as needed | 02/10/2010 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 91936005 | Penicillin | Rash and anaphylaxis | 06/10/2009 |
| Drug Allergy | 91939003 | Sulfonamides | Hives, photosensitivity | 04/25/1988 |
| Diagnostic Test Results | ||||
|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
| Imaging | 42272-5 | Chest X-ray, PA & Lateral | Hyperinflated lungs with flattened diaphragm and central pulmonary artery enlargement | 02/10/2010 |
| Hematology | 718-7 | Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) | 16 g/dl | 02/10/2010 |
| Hematology | 4544-3 | Hematocrit (male: 40-54% female: 36-48%) | 45% | 02/10/2010 |
