NIST-EP-Patient-2-Visit-1
From VistApedia
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 #2|Office Visit #1 for Robert Flint
Patient | |||||
---|---|---|---|---|---|
Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
Robert Flint | 04/18/1983 20:18:04 | Male | 9813624798 | Medical Record Number | 747 Market Street, Morton, Illinois 61550 309-365-8298 |
“Source” for all data for this patient: Carl Roberts, MD
Problem List | |||||
---|---|---|---|---|---|
Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
Diagnosis | 493.00 | Asthma, unspecified | Active | 07/19/2009 | |
Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
Disorder | 195967001 | Asthma | Active | 07/19/2009 |
Medication List | |||||||||
---|---|---|---|---|---|---|---|---|---|
RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
206833 | Medication | metaproterenol sulfate | Alupent Inhalation Aerosol | 15 mg/ml | 2 Puffs | Inhaled | Q4h | 07/19/2009 | Active |
Medication Allergy List | ||||
---|---|---|---|---|
Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
Drug Allergy | 91936005 | Penicillin | Rash and anaphylaxis | 08/10/2008 |
Drug Allergy | 293620004 | Indomethacin | Nausea, vomiting, rash, dizziness, headache | 03/25/2003 |
Diagnostic Test Results | ||||
---|---|---|---|---|
Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
Imaging | 24648-8 | Chest X-ray, PA | Increased bronchial wall markings, patchy infiltrates | 07/19/2009 |