NIST Ambulatory Test Patient 1

* 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

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