Difference between revisions of "NIST-EP-Patient-3-Visit-2"

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

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

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

@@ Line 22: / Line 22: @@
 |Female
 |9688675266
-|Medical Record Number
+|Medical [[Record~|Record]] Number
 |996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534
 |----
@@ Line 104: / Line 104: @@
 !scope="col"|Medication/Agent
 !scope="col"|Reaction
-!scope="col"|Date Recorded
+!scope="col"|Date [[Record~|Record]]ed
 |----
 |Drug [[Allergy~|Allergy]]