NIST-EP-Patient-1-Visit-2: Difference between revisions
From VistApedia
Jump to navigationJump to search
DaveMishler (talk | contribs) Initial data entry |
Added glossary link to Record~ |
||
| (2 intermediate revisions by 2 users not shown) | |||
| Line 22: | Line 22: | ||
|Male | |Male | ||
|969988999 | |969988999 | ||
|Medical Record Number | |Medical [[Record~|Record]] Number | ||
|478 Charles Street,<br>Williamsport,<br>Pennsylvania 17701<br>570-857-8593 | |478 Charles Street,<br>Williamsport,<br>Pennsylvania 17701<br>570-857-8593 | ||
|---- | |---- | ||
| Line 44: | Line 44: | ||
|02/20/2010 | |02/20/2010 | ||
|---- | |---- | ||
|---- | |---- | ||
!scope="col"|Type | !scope="col"|Type | ||
| Line 91: | Line 87: | ||
{| border="1"| | {| border="1"| | ||
!colspan="5"|Medication Allergy List | !colspan="5"|Medication [[Allergy~|Allergy]] List | ||
|---- | |---- | ||
!scope="col"|Type | !scope="col"|Type | ||
| Line 97: | Line 93: | ||
!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]] | ||
|293597001 | |293597001 | ||
|Codeine | |Codeine | ||
| Line 105: | Line 101: | ||
|06/27/1996 | |06/27/1996 | ||
|---- | |---- | ||
|Drug Allergy | |Drug [[Allergy~|Allergy]] | ||
|294506009 | |294506009 | ||
|Ampicillin | |Ampicillin | ||
Latest revision as of 12:36, 7 April 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 #1|Office Visit #2 for Jonas Barnaby
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Jonas Barnaby | 07/14/1961 12:30:24 | Male | 969988999 | Medical Record Number | 478 Charles Street, Williamsport, Pennsylvania 17701 570-857-8593 |
“Source” for all data for this patient: Marcus Welby, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Condition | 272.4 | Hyperlipidemia | Active | 02/20/2010 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 55822004 | Hyperlipidemia | Active | 02/20/2010 | |
| Medication List | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
| 617314 | Medication | atorvastatin calcium | Lipitor | 10 mg | 1 Tablet | PO | Q Day | 02/20/2010 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 293597001 | Codeine | Hives | 06/27/1996 |
| Drug Allergy | 294506009 | Ampicillin | Diarrhea, nausea, vomiting | 03/15/1994 |
| Diagnostic Test Results | ||||
|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
| Chemistry | 14647-2 | Total cholesterol (<200 mg/dl) | 262 mg/dl | 02/20/2010 |
| Chemistry | 14646-4 | HDL cholesterol (?40 mg/dl) | 78 mg/dl | 02/20/2010 |
| Chemistry | 2089-1 | LDL cholesterol (<100 mg/dl) | 184 mg/dl | 02/20/2010 |
| Chemistry | 14927-8 | Triglycerides (<150 mg/dl) | 177 mg/dl | 02/20/2010 |
