| 1 | TD170.306.f.: Exchange clinical information and patient summary record
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| 2 |
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| 3 | * indicates alternative standard code per certification criteria
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| 4 |
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| 5 | Patient Summary Record Test Data Set #1
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| 6 |
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| 7 | Patient
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| 8 | Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
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| 9 | Ann Toliver 07/16/1950 Female 989285998 Medical Record Number 353 Wine Street
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| 10 | 14:15:12 Flint,
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| 11 | Michigan 48503
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| 12 | 810-673-8378
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| 13 |
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| 14 | Source for all data for this patient: Fatima Goyal, MD
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| 15 |
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| 16 | Problem List
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| 17 | Type ICD-9 Code Patient Problem Status Date Diagnosed
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| 18 | Diagnosis 428.0 Congestive Heart Failure Active 02/22/2010
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| 19 | Diagnosis 410.90 Acute Myocardial Infarction Resolved 09/16/2007
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| 20 |
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| 21 | Type SNOMED Code* Patient Problem Status Date Diagnosed
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| 22 | Disorder 42343007 Congestive Heart Failure Active 02/22/2010
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| 23 | Disorder 57054005 Acute Myocardial Infarction Resolved 09/16/2007
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| 24 |
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| 25 | Medication List
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| 26 | RxNorm
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| 27 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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| 28 | Code
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| 29 | 201372 Medication captopril Capoten 25 mg Tablet PO TID 02/25/2010 Active
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| 30 | 200820 Medication spironolactone Aldactone 25 mg Tablet PO QID 02/25/2010 Active
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| 31 | 309888 Medication digoxin Lanoxin 125 mcg Tablet PO QD 02/25/2010 Active
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| 32 | potassium
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| 33 | 628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 02/25/2010 Active
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| 34 | chloride
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| 35 | 198039 Medication nitroglycerin Nitroglycerin 400 mcg 1 Tablet SL As needed 09/20/2007 Active
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| 36 |
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| 37 | Medication Allergy List
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| 38 | Type SNOMED Code Medication/Agent Reaction Date Recorded
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| 39 | Drug Allergy 293586001 Aspirin Wheezing 03/02/2007
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| 40 | Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 04/25/1994
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| 41 |
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| 42 | Diagnostic Test Results
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| 43 | Type LOINC Code Test (Normal Range) Result Date Performed
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| 44 | Enlarged cardiac silhouette,
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| 45 | Imaging 24648-8 Chest X-ray, PA 02/24/2010
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| 46 | lung fields clear
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| 47 | Chemistry 2951-2 Sodium (135146 mg/dl) 138 mg/dl 02/24/2010
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| 48 | Chemistry 2823-3 Potassium (3.55.3 mg/dl) 4.3 mg/dl 02/24/2010
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| 49 | Chemistry 2075-0 Chloride (95-107 mEq/L) 98 mEq/L 02/24/2010
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| 50 | Enlarged cardiac silhouette,
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| 51 | Imaging 24648-8 Chest X-ray, PA horizontal lines in the periphery 02/22/2010
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| 52 | of lower posterior lung fields
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| 53 | Chemistry 2951-2 Sodium (135146 mg/dl) 126 mg/dl 02/22/2010
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| 54 | Chemistry 2823-3 Potassium (3.55.3 mg/dl) 3.0 mg/dl 02/22/2010
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| 55 | Chemistry 2075-0 Chloride (95-107 mEq/L) 94 mEq/L 02/22/2010
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| 56 |
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| 57 | Procedure List
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| 58 | Type ICD-9 Code Procedure Status Date Performed
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| 59 | Cardiac 00.66 Percutaneous transluminal coronary angioplasty Completed 09/17/2007
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| 60 | Cardiac 37.21 Cardiac catheterization Completed 10/01/2006
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| 61 |
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| 62 | Type CPT Code* Procedure Status Date Performed
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| 63 | Cardiac 92982 Percutaneous transluminal coronary angioplasty Completed 09/17/2007
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| 64 | Cardiac 93501 Cardiac catheterization Completed 10/01/2006
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