Difference between revisions of "NIST-Inpatient-test-patient-1"

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#REDIRECT [[NIST-Inpatient-test-patient-2]]
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TD170.306.f.: Exchange clinical information and patient summary record
  
 +
* indicates alternative standard code per certification criteria
 +
 +
Patient Summary Record Test Data – Set #1
 +
 +
{| 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
 +
|----
 +
|Ann Toliver
 +
|07/16/1950<br>14:15:12
 +
|Female
 +
|989285998
 +
|Medical Record Number
 +
|353 Wine Street <br>Flint, <br>Michigan 48503 <br> 810-673-8378
 +
|----
 +
|}
 +
 +
“Source” for all data for this patient: Fatima Goyal, 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
 +
|428.0
 +
|Congestive Heart Failure
 +
|Active
 +
|02/22/2010
 +
|----
 +
|Diagnosis
 +
|410.90
 +
|Acute Myocardial Infarction
 +
|Resolved
 +
|09/16/2007
 +
|----
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|SNOMED Code*
 +
!scope="col"|Patient Problem
 +
!scope="col"|Status
 +
!scope="col"|Date Diagnosed
 +
|----
 +
|Disorder
 +
|42343007
 +
|Congestive Heart Failure
 +
|Active
 +
|02/22/2010
 +
|----
 +
|Disorder
 +
|57054005
 +
|Acute Myocardial Infarction
 +
|Resolved
 +
|09/16/2007
 +
|----
 +
|}
 +
 +
{| 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
 +
|----
 +
|201372
 +
|Medication
 +
|captopril
 +
|Capoten
 +
|25 mg
 +
|Tablet
 +
|PO
 +
|TID
 +
|02/25/2010
 +
|Active
 +
|----
 +
|200820
 +
|Medication
 +
|spironolactone
 +
|Aldactone
 +
|25 mg
 +
|Tablet
 +
|PO
 +
|QID
 +
|02/25/2010
 +
|Active
 +
|----
 +
|309888
 +
|Medication
 +
|digoxin
 +
|Lanoxin
 +
|125 mcg
 +
|Tablet
 +
|PO
 +
|QD
 +
|02/25/2010
 +
|Active
 +
|----
 +
|628958
 +
|Medication
 +
|potassium chloride
 +
|Klor-Con
 +
|10 mEq
 +
|1 Tablet
 +
|PO
 +
|BID
 +
|02/25/2010
 +
|Active
 +
|----
 +
|198039
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|Medication
 +
|nitroglycerin
 +
|Nitroglycerin
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|400 mcg
 +
|1 Tablet
 +
|SL
 +
|As needed
 +
|09/20/2007
 +
|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
 +
|293586001
 +
|Aspirin
 +
|Wheezing
 +
|03/02/2007
 +
|----
 +
|Drug Allergy
 +
|294506009
 +
|Ampicillin
 +
|Diarrhea, nausea, vomiting
 +
|04/25/1994
 +
|----
 +
|}
 +
 +
{| 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
 +
|----
 +
|Imaging
 +
|24648-8
 +
|Chest X-ray, PA
 +
|Enlarged cardiac silhouette, <br>lung fields clear
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|02/24/2010
 +
|----
 +
|Chemistry
 +
|2951-2
 +
|Sodium (135–146 mg/dl)
 +
|138 mg/dl
 +
|02/24/2010
 +
|----
 +
|Chemistry
 +
|2823-3
 +
|Potassium (3.5–5.3 mg/dl)
 +
|4.3 mg/dl
 +
|02/24/2010
 +
|----
 +
|Chemistry
 +
|2075-0
 +
|Chloride (95-107 mEq/L)
 +
|98 mEq/L
 +
|02/24/2010
 +
|----
 +
|Imaging
 +
|24648-8
 +
|Chest X-ray, PA
 +
|Enlarged cardiac silhouette, <br>horizontal lines in the periphery<br>of lower posterior lung fields
 +
|02/22/2010
 +
|----
 +
|Chemistry
 +
|2951-2
 +
|Sodium (135–146 mg/dl)
 +
|126 mg/dl
 +
|02/22/2010
 +
|----
 +
|Chemistry
 +
|2823-3
 +
|Potassium (3.5–5.3 mg/dl)
 +
|3.0 mg/dl
 +
|02/22/2010
 +
|----
 +
|Chemistry
 +
|2075-0
 +
|Chloride (95-107 mEq/L)
 +
|94 mEq/L
 +
|02/22/2010
 +
|----
 +
|}
 +
 +
{| border="1"|
 +
!colspan="5"|Procedure List
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|ICD-9 Code
 +
!scope="col"|Procedure
 +
!scope="col"|Status
 +
!scope="col"|Date Performed
 +
|----
 +
|Cardiac
 +
|00.66
 +
|Percutaneous transluminal coronary angioplasty
 +
|Completed
 +
|09/17/2007
 +
|----
 +
|Cardiac
 +
|37.21
 +
|Cardiac catheterization
 +
|Completed
 +
|10/01/2006
 +
|----
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|CPT Code*
 +
!scope="col"|Procedure
 +
!scope="col"|Status
 +
!scope="col"|Date Performed
 +
|----
 +
|Cardiac
 +
|92982
 +
|Percutaneous transluminal coronary angioplasty
 +
|Completed
 +
|09/17/2007
 +
|----
 +
|Cardiac
 +
|93501
 +
|Cardiac catheterization
 +
|Completed
 +
|10/01/2006
 +
|----
 +
|}
 +
--[[User:Glilly|Glilly]] 13:55, 22 Nov 2010 (PST)

Revision as of 21:55, 22 November 2010

TD170.306.f.: Exchange clinical information and patient summary record

  • 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
Ann Toliver 07/16/1950
14:15:12 		Female 989285998 Medical Record Number 353 Wine Street
Flint,
Michigan 48503
810-673-8378

“Source” for all data for this patient: Fatima Goyal, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 428.0 Congestive Heart Failure Active 02/22/2010
Diagnosis 410.90 Acute Myocardial Infarction Resolved 09/16/2007
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 42343007 Congestive Heart Failure Active 02/22/2010
Disorder 57054005 Acute Myocardial Infarction Resolved 09/16/2007
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
201372 Medication captopril Capoten 25 mg Tablet PO TID 02/25/2010 Active
200820 Medication spironolactone Aldactone 25 mg Tablet PO QID 02/25/2010 Active
309888 Medication digoxin Lanoxin 125 mcg Tablet PO QD 02/25/2010 Active
628958 Medication potassium chloride Klor-Con 10 mEq 1 Tablet PO BID 02/25/2010 Active
198039 Medication nitroglycerin Nitroglycerin 400 mcg 1 Tablet SL As needed 09/20/2007 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 293586001 Aspirin Wheezing 03/02/2007
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 04/25/1994
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Imaging 24648-8 Chest X-ray, PA Enlarged cardiac silhouette,
lung fields clear 		02/24/2010
Chemistry 2951-2 Sodium (135–146 mg/dl) 138 mg/dl 02/24/2010
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.3 mg/dl 02/24/2010
Chemistry 2075-0 Chloride (95-107 mEq/L) 98 mEq/L 02/24/2010
Imaging 24648-8 Chest X-ray, PA Enlarged cardiac silhouette,
horizontal lines in the periphery
of lower posterior lung fields 		02/22/2010
Chemistry 2951-2 Sodium (135–146 mg/dl) 126 mg/dl 02/22/2010
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 3.0 mg/dl 02/22/2010
Chemistry 2075-0 Chloride (95-107 mEq/L) 94 mEq/L 02/22/2010
Procedure List
Type ICD-9 Code Procedure Status Date Performed
Cardiac 00.66 Percutaneous transluminal coronary angioplasty Completed 09/17/2007
Cardiac 37.21 Cardiac catheterization Completed 10/01/2006
Type CPT Code* Procedure Status Date Performed
Cardiac 92982 Percutaneous transluminal coronary angioplasty Completed 09/17/2007
Cardiac 93501 Cardiac catheterization Completed 10/01/2006

--Glilly 13:55, 22 Nov 2010 (PST)

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