NIST-EP-Patient-1-Visit-1
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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 #1|Office Visit #1 for Jonas Barnaby
Patient | |||||
---|---|---|---|---|---|
Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
Jonas Barnaby | 07/14/1961 12:30:24 | Male | 969988999 | Medical Record Number | 478 Charles Street, Williamsport, Pennsylvania 17701 570-857-8593 |
“Source” for all data for this patient: Marcus Welby, MD
Problem List | |||||
---|---|---|---|---|---|
Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
Diagnosis | 250.02 | Diabetes Mellitus, Type 2 | Active | 07/20/2010 | |
Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
Disorder | 44054006 | Diabetes Mellitus, Type 2 | Active | 07/20/2010 |
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 | 07/20/2010 | 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 | 07/20/2010 |
--Glilly 19:00, 23 Nov 2010 (PST)