Difference between revisions of "NIST-EP-Patient-3-Visit-1"

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m (Added glossary link to Allergy~)
(Added glossary link to Record~)
 
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|Female
 
|Female
 
|9688675266
 
|9688675266
|Medical Record Number
+
|Medical [[Record~|Record]] Number
 
|996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534
 
|996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534
 
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!scope="col"|Medication/Agent
 
!scope="col"|Medication/Agent
 
!scope="col"|Reaction
 
!scope="col"|Reaction
!scope="col"|Date Recorded
+
!scope="col"|Date [[Record~|Record]]ed
 
|----
 
|----
 
|Drug [[Allergy~|Allergy]]
 
|Drug [[Allergy~|Allergy]]

Latest revision as of 12:57, 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 #3|Office Visit #1 for Barbara Simpson

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Barbara Simpson 10/12/1956 19:47:01 Female 9688675266 Medical Record Number 996 Dalton Street,
Fargo,
North Dakota 54102
701-366-5534

“Source” for all data for this patient: Robert James, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 486 Pneumonia Active 07/02/2010
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 233604007 Pneumonia Active 07/02/2010
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
308460 Medication azithromycin Azithromycin 250 mg 1 Tablet PO QD 07/02/2010 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 91936005 Penicillin Rash and anaphylaxis 06/10/2009
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 04/25/1988
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Imaging 42272-5 Chest X-ray, PA & Lateral Bilateral Pneumonia 07/02/2010
Cardiology 34534-8 Electrocardiogram Sinus Tachycardia 07/02/2010

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