Difference between revisions of "NIST-EP-Patient-2-Visit-2"

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m (Added glossary link to Allergy~)
(Added glossary link to Record~)
 
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|Male
 
|Male
 
|9813624798
 
|9813624798
|Medical Record Number
+
|Medical [[Record~|Record]] Number
 
|747 Market Street,<br>Morton,<br>Illinois 61550<br>309-365-8298
 
|747 Market Street,<br>Morton,<br>Illinois 61550<br>309-365-8298
 
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!scope="col"|Medication/Agent
 
!scope="col"|Medication/Agent
 
!scope="col"|Reaction
 
!scope="col"|Reaction
!scope="col"|Date Recorded
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!scope="col"|Date [[Record~|Record]]ed
 
|----
 
|----
 
|Drug [[Allergy~|Allergy]]
 
|Drug [[Allergy~|Allergy]]

Latest revision as of 12:41, 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 #2|Office Visit #2 for Robert Flint

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Robert Flint 04/18/1983 20:18:04 Male 9813624798 Medical Record Number 747 Market Street,
Morton,
Illinois 61550
309-365-8298

“Source” for all data for this patient: Carl Roberts, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 03/10/2010
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 44054006 Diabetes Mellitus, Type 2 Active 03/10/2010
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 03/10/2010 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
Chemistry 14771-0 Fasting Blood Glucose (70–100 mg/dl) 150 mg/dl 03/10/2010
Imaging 24648-8 Chest X-ray, PA The heart outline is normal and the hilar and mediastinal vessels are of normal appearance 03/10/2010

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