Difference between revisions of "NIST-EP-Patient-5-Visit-2"

From VistApedia
Jump to: navigation, search
(initial data entry)
 
m (Added glossary link to Allergy~)
Line 98: Line 98:
  
 
{| border="1"|
 
{| border="1"|
!colspan="5"|Medication Allergy List
+
!colspan="5"|Medication [[Allergy~|Allergy]] List
 
|----
 
|----
 
!scope="col"|Type
 
!scope="col"|Type
Line 106: Line 106:
 
!scope="col"|Date Recorded
 
!scope="col"|Date Recorded
 
|----
 
|----
|Drug Allergy
+
|Drug [[Allergy~|Allergy]]
 
|294506009
 
|294506009
 
|Ampicillin
 
|Ampicillin
Line 112: Line 112:
 
|03/25/1997
 
|03/25/1997
 
|----
 
|----
|Drug Allergy
+
|Drug [[Allergy~|Allergy]]
 
|91939003
 
|91939003
 
|Sulfonamides
 
|Sulfonamides

Revision as of 08:29, 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 #5|Office Visit #2 for Johnathan Stone

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Johnathan Stone 11/12/1966 08:18:08 Male 988772587 Medical Record Number 937 Sutter Street
Aurora,
Colorado 80011
303-544-9988

“Source” for all data for this patient: Samuel Johnston, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Symptom 401.9 Hypertension, Essential Active 01/15/2010
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 59621000 Essential Hypertension Active 01/15/2010
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 01/15/2010 Active
628958 Medication potassium chloride Klor-Con 10 mEq 1 Tablet PO BID 01/15/2010 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/25/1997
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 04/25/1989
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 01/15/2010
Imaging 42272-5 Chest X-ray, PA & Lateral The heart outline is normal and the hilar and mediastinal vessels are of normal appearance 01/15/2010

CSV format