NIST-Inpatient-test-patient-3
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Revision as of 13:58, 4 April 2012 by NeilArmstrong (talk | contribs) (Added a glossary link to Record~)
Patient Summary Record Test Data – Set #3
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Lorraine Blevins | 04/16/1957 20:15:35 |
Female | 967385998 | Medical Record Number | 1020 Stuart Street Morton, Illinois 61550 309-374-8938 |
“Source” for all data for this patient: Louis Randolph, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Diagnosis | 715.35 | Right hip osteoarthritis | Resolved | 02/12/2010 | |
| Finding | 414.01 | Coronary Artery Disease (CAD) | Chronic | 05/05/2002 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 239872002 | Right hip osteoarthritis | Resolved | 02/12/2010 | |
| Disorder | 53741008 | Coronary Arteriosclerosis | Chronic | 05/05/2002 | |
| Medication List | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
| 855320 | Medication | warfarin | Coumadin | 3 mg | 1 Tablet | PO | QD | 02/15/2010 | Active |
| 209613 | Medication | bisacodyl | Dulcolax | 5 mg | 1 Tablet | PO | QD | 02/15/2010 | Active |
| 309362 | Medication | clopidogrel | Plavix | 75 mg | 1 Tablet | PO | QD | 05/15/2002 | Active |
| 197361 | Medication | amlodipine | Norvasc | 5 mg | 1 Tablet | PO | QD | 07/15/2009 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 91939003 | Sulfonamides | Hives, photosensitivity | 06/06/1998 |
| Drug Allergy | 294506009 | Ampicillin | Diarrhea, nausea, vomiting | 04/25/1994 |
| Diagnostic Test Results | ||||
|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
| Imaging | 37721-8 | X-ray, 2 views, Right Hip | Subchondral sclerosis, increased density in subchondral bone |
02/12/2010 |
| Imaging | 24648-8 | Chest X-ray, PA | No disease is seen in the lung fields or pleura |
06/05/2009 |
| Hematology | 718-7 | Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) |
11.2 g/dl | 06/05/2009 |
| Hematology | 4544-3 | Hematocrit (male: 40-54% female: 36-48%) |
34% | 06/05/2009 |
| Coagulation | 34714-6 | Prothrombin Time/ International Normalized Ratio (PT/INR) (2.5 – 3.5) |
3.1 | 06/05/2009 |
| Procedure List | ||||
|---|---|---|---|---|
| Type | ICD-9 Code | Procedure | Status | Date Performed |
| Surgical | 81.51 | Total Hip Replacement, Right | Completed | 02/14/2010 |
| Cardiac | 37.21 | Cardiac catheterization | Completed | 05/05/2002 |
| Type | CPT Code* | Procedure | Status | Date Performed |
| Surgical | 27130 | Total Hip Replacement, Right | Completed | 02/14/2010 |
| Cardiac | 93501 | Cardiac catheterization | Completed | 05/05/2002 |
--Glilly 11:35, 22 Nov 2010 (PST)
