NIST Ambulatory Test Patient 2: Difference between revisions
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DaveMishler (talk | contribs) initial data entry |
Added glossary link to Record~ |
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Test Procedure for §170.304. | Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary [[Record~|Record]] | ||
APPROVED (Pending) Version 1.0 July 21, 2010 | APPROVED (Pending) Version 1.0 July 21, 2010 | ||
Patient Summary Record Test Data – Set #2 | Patient Summary [[Record~|Record]] Test Data – Set #2 | ||
{| border="1"| | {| border="1"| | ||
| Line 18: | Line 18: | ||
|Male | |Male | ||
|9813466798 | |9813466798 | ||
|Medical Record Number | |Medical [[Record~|Record]] Number | ||
|355 Elm Street<br>Morton,<br>Illinois 61550<br>309-377-8365 | |355 Elm Street<br>Morton,<br>Illinois 61550<br>309-377-8365 | ||
|---- | |---- | ||
| Line 106: | Line 106: | ||
{| border="1"| | {| border="1"| | ||
!colspan="5"|Medication Allergy List | !colspan="5"|Medication [[Allergy~|Allergy]] List | ||
|---- | |---- | ||
!scope="col"|Type | !scope="col"|Type | ||
| Line 112: | Line 112: | ||
!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]] | ||
|91936005 | |91936005 | ||
|Penicillin | |Penicillin | ||
| Line 120: | Line 120: | ||
|08/10/2008 | |08/10/2008 | ||
|---- | |---- | ||
|Drug Allergy | |Drug [[Allergy~|Allergy]] | ||
|293620004 | |293620004 | ||
|Indomethacin | |Indomethacin | ||
Latest revision as of 13:08, 7 April 2012
Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary Record APPROVED (Pending) Version 1.0 July 21, 2010
Patient Summary Record Test Data – Set #2
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Ralph Johnson | 06/28/1984 13:20:10 | Male | 9813466798 | Medical Record Number | 355 Elm Street Morton, Illinois 61550 309-377-8365 |
“Source” for all data for this patient: Carl Roberts, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Diagnosis | 493.00 | Asthma, unspecified | Active | 12/22/2009 | |
| Diagnosis | 250.02 | Diabetes Mellitus, Type 2 | Active | 08/10/2008 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 195967001 | Asthma | Active | 12/22/2009 | |
| Disorder | 44054006 | Diabetes Mellitus, Type 2 | Active | 08/10/2008 | |
| Medication List | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
| 206833 | Medication | metaproternol sulfate | Alupent Inhalation Aerosol | 15 mg/ml | 2 Puffs | Inhaled | Q4h | 12/22/2009 | Active |
| 205875 | Medication | glyburide | Diabeta | 2.5 mg | 1 Tablet | PO | Q AM | 08/10/2008 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 91936005 | Penicillin | Rash and anaphylaxis | 08/10/2008 |
| Drug Allergy | 293620004 | Indomethacin | Nausea, vomiting, rash, dizziness, headache |
03/25/2003 |
| Diagnostic Test Results | ||||
|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
| Imaging | 24648-8 | Chest X-ray, PA | Increased bronchial wall markings, patchy infiltrates |
02/16/2010 |
| Chemistry | 14771-0 | Fasting Blood Glucose (70–100 mg/dl) | 70 mg/dl | 12/22/2009 |
| Hematology | 26449-9 | Eosinophil Count (1 – 3 %) | 2% | 12/22/2009 |
| Imaging | 24648-8 | Chest X-ray, PA | Bronchial wall markings | 12/22/2009 |
