NIST Ambulatory Test Patient 1

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* indicates alternative standard code per certification criteria

Patient Summary Record Test Data – Set #1

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
John D. Smith 07/04/1960 10:15:02 Male 999999999 Medical Record Number 355 Maple Street
Williamsport,
Pennsylvania 17701
570-837-8364

“Source” for all data for this patient: John Fitzgerald, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 09/16/2009
Condition 272.4 Hyperlipidemia Active 05/05/2002
Finding 414.01 Coronary Artery Disease (CAD) Chronic 05/05/2002
Symptom 401.9 Hypertension, Essential Active 05/05/2002
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 44054006 Diabetes Mellitus, Type 2 Active 09/16/2009
Disorder 55822004 Hyperlipidemia Active 05/05/2002
Disorder 53741008 Coronary Arteriosclerosis Chronic 05/05/2002
Disorder 59621000 Essential Hypertension Active 05/05/2002
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 09/16/2009 Active
617314 Medication atorvastatin calcium Lipitor 10 mg 1 Tablet PO Q Day 05/05/2002 Active
200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 05/05/2002 Active
628958 Medication potassium chloride Klor-Con 10 mEq 1 Tablet PO BID 05/05/2002 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 09/16/2009
Chemistry 14682-9 Creatinine (0.5–1.4 mg/dl) 1.0 mg/dl 09/16/2009
Chemistry 14937-7 BUN (7–30 mg/dl) 18 mg/dl 09/16/2009
Chemistry 2951-2 Sodium (135–146 mg/dl) 141 mg/dl 09/16/2009
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.3 mg/dl 09/16/2009
Chemistry 14647-2 Total cholesterol (<200 mg/dl) 162 mg/dl 09/16/2009
Chemistry 14646-4 HDL cholesterol (?40 mg/dl) 43 mg/dl 09/16/2009
Chemistry 2089-1 LDL cholesterol (<100 mg/dl) 84 mg/dl 09/16/2009
Chemistry 14927-8 Triglycerides (<150 mg/dl) 177 mg/dl 09/16/2009
Imaging 24648-8 Chest X-ray, PA No disease is seen in the
lung fields or pleura 		09/16/2009

CSV Format

--Glilly 23:27, 21 Nov 2010 (PST)

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