NIST-EP-Patient-5-Visit-1: Difference between revisions
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DaveMishler (talk | contribs) initial data entry |
Added glossary link to Record~ |
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|Male | |Male | ||
|988772587 | |988772587 | ||
|Medical Record Number | |Medical [[Record~|Record]] Number | ||
|937 Sutter Street<br>Aurora,<br>Colorado 80011<br>303-544-9988 | |937 Sutter Street<br>Aurora,<br>Colorado 80011<br>303-544-9988 | ||
|---- | |---- | ||
| Line 87: | Line 87: | ||
{| border="1"| | {| border="1"| | ||
!colspan="5"|Medication Allergy List | !colspan="5"|Medication [[Allergy~|Allergy]] List | ||
|---- | |---- | ||
!scope="col"|Type | !scope="col"|Type | ||
| Line 93: | Line 93: | ||
!scope="col"|Medication/Agent | !scope="col"|Medication/Agent | ||
!scope="col"|Reaction | !scope="col"|Reaction | ||
!scope="col"|Date | !scope="col"|Date [[Record~|Record]]ed | ||
|---- | |---- | ||
|Drug Allergy | |Drug [[Allergy~|Allergy]] | ||
|294506009 | |294506009 | ||
|Ampicillin | |Ampicillin | ||
| Line 101: | Line 101: | ||
|03/25/1997 | |03/25/1997 | ||
|---- | |---- | ||
|Drug Allergy | |Drug [[Allergy~|Allergy]] | ||
|91939003 | |91939003 | ||
|Sulfonamides | |Sulfonamides | ||
Latest revision as of 13:04, 7 April 2012
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 #5|Office Visit #1 for Johnathan Stone
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Johnathan Stone | 11/12/1966 08:18:08 | Male | 988772587 | Medical Record Number | 937 Sutter Street Aurora, Colorado 80011 303-544-9988 |
“Source” for all data for this patient: Samuel Johnston, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Diagnosis | 250.02 | Diabetes Mellitus, Type 2 | Active | 07/17/2010 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 44054006 | Diabetes Mellitus, Type 2 | Active | 07/17/2010 | |
| 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 | 07/17/2010 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 294506009 | Ampicillin | Diarrhea, nausea, vomiting | 03/25/1997 |
| Drug Allergy | 91939003 | Sulfonamides | Hives, photosensitivity | 04/25/1989 |
| Diagnostic Test Results | |||||
|---|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed | |
| Chemistry | 14771-0 | LOINC | Fasting Blood Glucose (70–100 mg/dl) | 120 mg/dl | 07/17/2010 |
