Difference between revisions of "NIST-EP-Patient-5-Visit-2"

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|Male
 
|Male
 
|988772587
 
|988772587
|Medical Record Number
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|Medical [[Record~|Record]] Number
 
|937 Sutter Street<br>Aurora,<br>Colorado 80011<br>303-544-9988
 
|937 Sutter Street<br>Aurora,<br>Colorado 80011<br>303-544-9988
 
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{| border="1"|
 
{| border="1"|
!colspan="5"|Medication Allergy List
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!colspan="5"|Medication [[Allergy~|Allergy]] List
 
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!scope="col"|Type
 
!scope="col"|Type
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!scope="col"|Medication/Agent
 
!scope="col"|Medication/Agent
 
!scope="col"|Reaction
 
!scope="col"|Reaction
!scope="col"|Date Recorded
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!scope="col"|Date [[Record~|Record]]ed
 
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|Drug Allergy
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|Drug [[Allergy~|Allergy]]
 
|294506009
 
|294506009
 
|Ampicillin
 
|Ampicillin
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|03/25/1997
 
|03/25/1997
 
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|Drug Allergy
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|Drug [[Allergy~|Allergy]]
 
|91939003
 
|91939003
 
|Sulfonamides
 
|Sulfonamides

Latest revision as of 13:06, 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 #5|Office Visit #2 for Johnathan Stone

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Johnathan Stone 11/12/1966 08:18:08 Male 988772587 Medical Record Number 937 Sutter Street
Aurora,
Colorado 80011
303-544-9988

“Source” for all data for this patient: Samuel Johnston, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Symptom 401.9 Hypertension, Essential Active 01/15/2010
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 59621000 Essential Hypertension Active 01/15/2010
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 01/15/2010 Active
628958 Medication potassium chloride Klor-Con 10 mEq 1 Tablet PO BID 01/15/2010 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/25/1997
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 04/25/1989
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.5 mg/dl 01/15/2010
Imaging 42272-5 Chest X-ray, PA & Lateral The heart outline is normal and the hilar and mediastinal vessels are of normal appearance 01/15/2010

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