NIST Ambulatory Test Patient 2
From VistApedia
Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary Record APPROVED (Pending) Version 1.0 July 21, 2010
Patient Summary Record Test Data – Set #2
Patient | |||||
---|---|---|---|---|---|
Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
Ralph Johnson | 06/28/1984 13:20:10 | Male | 9813466798 | Medical Record Number | 355 Elm Street Morton, Illinois 61550 309-377-8365 |
“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 | 12/22/2009 | |
Diagnosis | 250.02 | Diabetes Mellitus, Type 2 | Active | 08/10/2008 | |
Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
Disorder | 195967001 | Asthma | Active | 12/22/2009 | |
Disorder | 44054006 | Diabetes Mellitus, Type 2 | Active | 08/10/2008 |
Medication List | |||||||||
---|---|---|---|---|---|---|---|---|---|
RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
206833 | Medication | metaproternol sulfate | Alupent Inhalation Aerosol | 15 mg/ml | 2 Puffs | Inhaled | Q4h | 12/22/2009 | Active |
205875 | Medication | glyburide | Diabeta | 2.5 mg | 1 Tablet | PO | Q AM | 08/10/2008 | 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 |
02/16/2010 |
Chemistry | 14771-0 | Fasting Blood Glucose (70–100 mg/dl) | 70 mg/dl | 12/22/2009 |
Hematology | 26449-9 | Eosinophil Count (1 – 3 %) | 2% | 12/22/2009 |
Imaging | 24648-8 | Chest X-ray, PA | Bronchial wall markings | 12/22/2009 |