Difference between revisions of "NIST-EP-Patient-4-Visit-2"

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Revision as of 08:26, 22 February 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 #4|Office Visit #2 for Susan Ellerby

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Susan Ellerby 12/08/1963 21:54:24 Female 925377799 Medical Record Number 483 Powell Street,
Shawville,
Pennsylvania 16873
814-645-9475

“Source” for all data for this patient: Dorcas Wayne, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Symptom 401.9 Hypertension, Essential Active 02/05/2010
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 59621000 Essential Hypertension Active 02/05/2010
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 02/05/2010 Active
628958 Medication potassium chloride Klor-Con 10 mEq 1 Tablet PO BID 02/05/2010 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 91936005 Penicillin Rash and anaphylaxis 05/22/1998
Drug Allergy 293597001 Codeine Hives 02/17/1992
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.5 mg/dl 02/05/2010
Imaging 42272-5 Chest X-ray, PA & Lateral The heart outline is normal and the hilar and mediastinal vessels are of normal appearance 02/05/2010

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