Difference between revisions of "NIST Ambulatory Test Patient 1"

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This is the Sandbox page. Use this page to test your skills.
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* indicates alternative standard code per certification criteria
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Patient Summary Record Test Data – Set #1
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 +
{| border="1"|
 +
!colspan="6"|Patient
 +
|----
 +
!scope="col"|Name
 +
!scope="col"|Date/Time of Birth
 +
!scope="col"|Gender
 +
!scope="col"|Identification Number
 +
!scope="col"|Identification Number Type
 +
!scope="col"|Address/Phone
 +
|----
 +
|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
 +
|----
 +
|}
 +
 
 +
“Source” for all data for this patient: John Fitzgerald, MD
 +
 
 +
{| border="1"|
 +
!colspan="6"|Problem List
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|ICD-9 Code
 +
!scope="col"|Patient Problem
 +
!scope="col"|Status
 +
!scope="col"|Date Diagnosed
 +
|----
 +
|Diagnosis
 +
|250.02
 +
|Diabetes Mellitus, Type 2
 +
|Active
 +
|09/16/2009
 +
|----
 +
|Condition
 +
|272.4
 +
|Hyperlipidemia
 +
|Active
 +
|05/05/2002
 +
|----
 +
|Finding
 +
|414.01
 +
|Coronary Artery Disease (CAD)
 +
|Chronic
 +
|05/05/2002
 +
|----
 +
|Symptom
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|401.9
 +
|Hypertension, Essential
 +
|Active
 +
|05/05/2002
 +
|----
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|SNOMED Code*
 +
!scope="col"|Patient Problem
 +
!scope="col"|Status
 +
!scope="col"|Date Diagnosed
 +
|----
 +
|Disorder
 +
|44054006
 +
|Diabetes Mellitus, Type 2
 +
|Active
 +
|09/16/2009
 +
|----
 +
|Disorder
 +
|55822004
 +
|Hyperlipidemia
 +
|Active
 +
|05/05/2002
 +
|----
 +
|Disorder
 +
|53741008
 +
|Coronary Arteriosclerosis
 +
|Chronic
 +
|05/05/2002
 +
|----
 +
|Disorder
 +
|59621000
 +
|Essential Hypertension
 +
|Active
 +
|05/05/2002
 +
|----
 +
|}
 +
 
 +
{| border="1"|
 +
!colspan="10"|Medication List
 +
|----
 +
!scope="col"|RxNorm Code
 +
!scope="col"|Product
 +
!scope="col"|Generic Name
 +
!scope="col"|Brand Name
 +
!scope="col"|Strength
 +
!scope="col"|Dose
 +
!scope="col"|Route
 +
!scope="col"|Frequency
 +
!scope="col"|Date Started
 +
!scope="col"|Status
 +
|----
 +
|205875
 +
|Medication
 +
|glyburide
 +
|Diabeta
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|2.5 mg
 +
|1 Tablet
 +
|PO
 +
|Q AM
 +
|09/16/2009
 +
|Active
 +
|----
 +
|617314
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|Medication
 +
|atorvastatin calcium
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|Lipitor
 +
|10 mg
 +
|1 Tablet
 +
|PO
 +
|Q Day
 +
|05/05/2002
 +
|Active
 +
|----
 +
|200801
 +
|Medication
 +
|furosemide
 +
|Lasix
 +
|20 mg
 +
|1 Tablet
 +
|PO
 +
|BID
 +
|05/05/2002
 +
|Active
 +
|----
 +
|628958
 +
|Medication
 +
|potassium chloride
 +
|Klor-Con
 +
|10 mEq
 +
|1 Tablet
 +
|PO
 +
|BID
 +
|05/05/2002
 +
|Active
 +
|----
 +
|}
 +
 
 +
{| border="1"|
 +
!colspan="5"|Medication Allergy List
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|SNOMED Code
 +
!scope="col"|Medication/Agent
 +
!scope="col"|Reaction
 +
!scope="col"|Date Recorded
 +
|----
 +
|Drug Allergy
 +
|293597001
 +
|Codeine
 +
|Hives
 +
|06/27/1996
 +
|----
 +
|Drug Allergy
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|294506009
 +
|Ampicillin
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|Diarrhea, nausea, vomiting
 +
|03/15/1994
 +
|----
 +
|}
 +
 
 +
{| border="1"|
 +
!colspan="5"|Diagnostic Test Results
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|LOINC Code
 +
!scope="col"|Test (Normal Range)
 +
!scope="col"|Result
 +
!scope="col"|Date Performed
 +
|----
 +
|Chemistry
 +
|14771-0
 +
|Fasting Blood Glucose (70–100 mg/dl)
 +
|178 mg/dl
 +
|09/16/2009
 +
|----
 +
|Chemistry
 +
|14682-9
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|Creatinine (0.5–1.4 mg/dl)
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|1.0 mg/dl
 +
|09/16/2009
 +
|----
 +
|Chemistry
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|14937-7
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|BUN (7–30 mg/dl)
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|18 mg/dl
 +
|09/16/2009
 +
|----
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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
 +
|09/16/2009
 +
|----
 +
|Chemistry
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|2823-3
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|Potassium (3.5–5.3 mg/dl)
 +
|4.3 mg/dl
 +
|09/16/2009
 +
|----
 +
|Chemistry
 +
|14647-2
 +
|Total cholesterol (<200 mg/dl)
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|162 mg/dl
 +
|09/16/2009
 +
|----
 +
|Chemistry
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|14646-4
 +
|HDL cholesterol (?40 mg/dl)
 +
|43 mg/dl
 +
|09/16/2009
 +
|----
 +
|Chemistry
 +
|2089-1
 +
|LDL cholesterol (<100 mg/dl)
 +
|84 mg/dl
 +
|09/16/2009
 +
|----
 +
|Chemistry
 +
|14927-8
 +
|Triglycerides (<150 mg/dl)
 +
|177 mg/dl
 +
|09/16/2009
 +
|----
 +
|Imaging
 +
|24648-8
 +
|Chest X-ray, PA
 +
|No disease is seen in the<br>lung fields or pleura
 +
|09/16/2009
 +
|----
 +
|}
 +
--[[User:Glilly|Glilly]] 23:27, 21 Nov 2010 (PST)

Revision as of 07:27, 22 November 2010

* indicates alternative standard code per certification criteria

Patient Summary Record Test Data – Set #1

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
John D. Smith 07/04/1960 10:15:02 Male 999999999 Medical Record Number 355 Maple Street
Williamsport,
Pennsylvania 17701
570-837-8364

“Source” for all data for this patient: John Fitzgerald, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 09/16/2009
Condition 272.4 Hyperlipidemia Active 05/05/2002
Finding 414.01 Coronary Artery Disease (CAD) Chronic 05/05/2002
Symptom 401.9 Hypertension, Essential Active 05/05/2002
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 44054006 Diabetes Mellitus, Type 2 Active 09/16/2009
Disorder 55822004 Hyperlipidemia Active 05/05/2002
Disorder 53741008 Coronary Arteriosclerosis Chronic 05/05/2002
Disorder 59621000 Essential Hypertension Active 05/05/2002
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 09/16/2009 Active
617314 Medication atorvastatin calcium Lipitor 10 mg 1 Tablet PO Q Day 05/05/2002 Active
200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 05/05/2002 Active
628958 Medication potassium chloride Klor-Con 10 mEq 1 Tablet PO BID 05/05/2002 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 293597001 Codeine Hives 06/27/1996
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/15/1994
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Chemistry 14771-0 Fasting Blood Glucose (70–100 mg/dl) 178 mg/dl 09/16/2009
Chemistry 14682-9 Creatinine (0.5–1.4 mg/dl) 1.0 mg/dl 09/16/2009
Chemistry 14937-7 BUN (7–30 mg/dl) 18 mg/dl 09/16/2009
Chemistry 2951-2 Sodium (135–146 mg/dl) 141 mg/dl 09/16/2009
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.3 mg/dl 09/16/2009
Chemistry 14647-2 Total cholesterol (<200 mg/dl) 162 mg/dl 09/16/2009
Chemistry 14646-4 HDL cholesterol (?40 mg/dl) 43 mg/dl 09/16/2009
Chemistry 2089-1 LDL cholesterol (<100 mg/dl) 84 mg/dl 09/16/2009
Chemistry 14927-8 Triglycerides (<150 mg/dl) 177 mg/dl 09/16/2009
Imaging 24648-8 Chest X-ray, PA No disease is seen in the
lung fields or pleura 		09/16/2009

--Glilly 23:27, 21 Nov 2010 (PST)

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