NIST-EP-Patient-3-Visit-1

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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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