Difference between revisions of "NIST-Inpatient-test-patient-1"

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Revision as of 08:16, 22 February 2012

TD170.306.f.: Exchange clinical information and patient summary record

  • 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
Ann Toliver 07/16/1950
14:15:12 		Female 989285998 Medical Record Number 353 Wine Street
Flint,
Michigan 48503
810-673-8378

“Source” for all data for this patient: Fatima Goyal, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 428.0 Congestive Heart Failure Active 02/22/2010
Diagnosis 410.90 Acute Myocardial Infarction Resolved 09/16/2007
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 42343007 Congestive Heart Failure Active 02/22/2010
Disorder 57054005 Acute Myocardial Infarction Resolved 09/16/2007
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
201372 Medication captopril Capoten 25 mg Tablet PO TID 02/25/2010 Active
200820 Medication spironolactone Aldactone 25 mg Tablet PO QID 02/25/2010 Active
309888 Medication digoxin Lanoxin 125 mcg Tablet PO QD 02/25/2010 Active
628958 Medication potassium chloride Klor-Con 10 mEq 1 Tablet PO BID 02/25/2010 Active
198039 Medication nitroglycerin Nitroglycerin 400 mcg 1 Tablet SL As needed 09/20/2007 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 293586001 Aspirin Wheezing 03/02/2007
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 04/25/1994
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Imaging 24648-8 Chest X-ray, PA Enlarged cardiac silhouette,
lung fields clear 		02/24/2010
Chemistry 2951-2 Sodium (135–146 mg/dl) 138 mg/dl 02/24/2010
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.3 mg/dl 02/24/2010
Chemistry 2075-0 Chloride (95-107 mEq/L) 98 mEq/L 02/24/2010
Imaging 24648-8 Chest X-ray, PA Enlarged cardiac silhouette,
horizontal lines in the periphery
of lower posterior lung fields 		02/22/2010
Chemistry 2951-2 Sodium (135–146 mg/dl) 126 mg/dl 02/22/2010
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 3.0 mg/dl 02/22/2010
Chemistry 2075-0 Chloride (95-107 mEq/L) 94 mEq/L 02/22/2010
Procedure List
Type ICD-9 Code Procedure Status Date Performed
Cardiac 00.66 Percutaneous transluminal coronary angioplasty Completed 09/17/2007
Cardiac 37.21 Cardiac catheterization Completed 10/01/2006
Type CPT Code* Procedure Status Date Performed
Cardiac 92982 Percutaneous transluminal coronary angioplasty Completed 09/17/2007
Cardiac 93501 Cardiac catheterization Completed 10/01/2006

CSV Format

--Glilly 13:55, 22 Nov 2010 (PST)

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