NIST-Inpatient-test-patient-1: Difference between revisions
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Added glossary link to Record~ |
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TD170.306.f.: Exchange clinical information and patient summary record | TD170.306.f.: Exchange clinical information and patient summary [[record~|Record]] | ||
* indicates alternative standard code per certification criteria | * indicates alternative standard code per certification criteria | ||
Patient Summary Record Test Data – Set #1 | Patient Summary [[Record~|Record]] Test Data – Set #1 | ||
{| border="1"| | {| border="1"| | ||
| Line 19: | Line 19: | ||
|Female | |Female | ||
|989285998 | |989285998 | ||
|Medical Record Number | |Medical [[Record~|Record]] Number | ||
|353 Wine Street <br>Flint, <br>Michigan 48503 <br> 810-673-8378 | |353 Wine Street <br>Flint, <br>Michigan 48503 <br> 810-673-8378 | ||
|---- | |---- | ||
| Line 140: | Line 140: | ||
{| border="1"| | {| border="1"| | ||
!colspan="5"|Medication Allergy List | !colspan="5"|Medication [[Allergy~|Allergy]] List | ||
|---- | |---- | ||
!scope="col"|Type | !scope="col"|Type | ||
| Line 146: | Line 146: | ||
!scope="col"|Medication/Agent | !scope="col"|Medication/Agent | ||
!scope="col"|Reaction | !scope="col"|Reaction | ||
!scope="col"|Date | !scope="col"|Date [[Record~|Record]]ed | ||
|---- | |---- | ||
|Drug Allergy | |Drug [[Allergy~|Allergy]] | ||
|293586001 | |293586001 | ||
|Aspirin | |Aspirin | ||
| Line 154: | Line 154: | ||
|03/02/2007 | |03/02/2007 | ||
|---- | |---- | ||
|Drug Allergy | |Drug [[Allergy~|Allergy]] | ||
|294506009 | |294506009 | ||
|Ampicillin | |Ampicillin | ||
| Line 262: | Line 262: | ||
|---- | |---- | ||
|} | |} | ||
[https://trac.opensourcevista.net/browser/hData/trunk/test-patients/NIST-Inpatient-test-patient-1.csv CSV Format] | |||
--[[User:Glilly|Glilly]] 13:55, 22 Nov 2010 (PST) | --[[User:Glilly|Glilly]] 13:55, 22 Nov 2010 (PST) | ||
Latest revision as of 12:22, 7 April 2012
TD170.306.f.: Exchange clinical information and patient summary Record
- indicates alternative standard code per certification criteria
Patient Summary Record Test Data – Set #1
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Ann Toliver | 07/16/1950 14:15:12 |
Female | 989285998 | Medical Record Number | 353 Wine Street Flint, Michigan 48503 810-673-8378 |
“Source” for all data for this patient: Fatima Goyal, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Diagnosis | 428.0 | Congestive Heart Failure | Active | 02/22/2010 | |
| Diagnosis | 410.90 | Acute Myocardial Infarction | Resolved | 09/16/2007 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 42343007 | Congestive Heart Failure | Active | 02/22/2010 | |
| Disorder | 57054005 | Acute Myocardial Infarction | Resolved | 09/16/2007 | |
| Medication List | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
| 201372 | Medication | captopril | Capoten | 25 mg | Tablet | PO | TID | 02/25/2010 | Active |
| 200820 | Medication | spironolactone | Aldactone | 25 mg | Tablet | PO | QID | 02/25/2010 | Active |
| 309888 | Medication | digoxin | Lanoxin | 125 mcg | Tablet | PO | QD | 02/25/2010 | Active |
| 628958 | Medication | potassium chloride | Klor-Con | 10 mEq | 1 Tablet | PO | BID | 02/25/2010 | Active |
| 198039 | Medication | nitroglycerin | Nitroglycerin | 400 mcg | 1 Tablet | SL | As needed | 09/20/2007 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 293586001 | Aspirin | Wheezing | 03/02/2007 |
| Drug Allergy | 294506009 | Ampicillin | Diarrhea, nausea, vomiting | 04/25/1994 |
| Diagnostic Test Results | ||||
|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
| Imaging | 24648-8 | Chest X-ray, PA | Enlarged cardiac silhouette, lung fields clear |
02/24/2010 |
| Chemistry | 2951-2 | Sodium (135–146 mg/dl) | 138 mg/dl | 02/24/2010 |
| Chemistry | 2823-3 | Potassium (3.5–5.3 mg/dl) | 4.3 mg/dl | 02/24/2010 |
| Chemistry | 2075-0 | Chloride (95-107 mEq/L) | 98 mEq/L | 02/24/2010 |
| Imaging | 24648-8 | Chest X-ray, PA | Enlarged cardiac silhouette, horizontal lines in the periphery of lower posterior lung fields |
02/22/2010 |
| Chemistry | 2951-2 | Sodium (135–146 mg/dl) | 126 mg/dl | 02/22/2010 |
| Chemistry | 2823-3 | Potassium (3.5–5.3 mg/dl) | 3.0 mg/dl | 02/22/2010 |
| Chemistry | 2075-0 | Chloride (95-107 mEq/L) | 94 mEq/L | 02/22/2010 |
| Procedure List | ||||
|---|---|---|---|---|
| Type | ICD-9 Code | Procedure | Status | Date Performed |
| Cardiac | 00.66 | Percutaneous transluminal coronary angioplasty | Completed | 09/17/2007 |
| Cardiac | 37.21 | Cardiac catheterization | Completed | 10/01/2006 |
| Type | CPT Code* | Procedure | Status | Date Performed |
| Cardiac | 92982 | Percutaneous transluminal coronary angioplasty | Completed | 09/17/2007 |
| Cardiac | 93501 | Cardiac catheterization | Completed | 10/01/2006 |
--Glilly 13:55, 22 Nov 2010 (PST)
