NIST-EP-Patient-2-Visit-2
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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 #2|Office Visit #2 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 | 250.02 | Diabetes Mellitus, Type 2 | Active | 03/10/2010 | |
Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
Disorder | 44054006 | Diabetes Mellitus, Type 2 | Active | 03/10/2010 |
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 | 03/10/2010 | 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 |
Chemistry | 14771-0 | Fasting Blood Glucose (70–100 mg/dl) | 150 mg/dl | 03/10/2010 |
Imaging | 24648-8 | Chest X-ray, PA | The heart outline is normal and the hilar and mediastinal vessels are of normal appearance | 03/10/2010 |