NIST-EP-Patient-4-Visit-2
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 #4|Office Visit #2 for Susan Ellerby
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Susan Ellerby | 12/08/1963 21:54:24 | Female | 925377799 | Medical Record Number | 483 Powell Street, Shawville, Pennsylvania 16873 814-645-9475 |
“Source” for all data for this patient: Dorcas Wayne, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Symptom | 401.9 | Hypertension, Essential | Active | 02/05/2010 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 59621000 | Essential Hypertension | Active | 02/05/2010 | |
| 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 | 02/05/2010 | Active |
| 628958 | Medication | potassium chloride | Klor-Con | 10 mEq | 1 Tablet | PO | BID | 02/05/2010 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 91936005 | Penicillin | Rash and anaphylaxis | 05/22/1998 |
| Drug Allergy | 293597001 | Codeine | Hives | 02/17/1992 |
| 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 | 02/05/2010 |
| Imaging | 42272-5 | Chest X-ray, PA & Lateral | The heart outline is normal and the hilar and mediastinal vessels are of normal appearance | 02/05/2010 |
