1 | * indicates alternative standard code per certification criteria
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2 |
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3 | Patient Summary Record Test Data Set #1
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4 |
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5 | {| border="1"|
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6 | !colspan="6"|Patient
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7 | |----
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8 | !scope="col"|Name
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9 | !scope="col"|Date/Time of Birth
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10 | !scope="col"|Gender
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11 | !scope="col"|Identification Number
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12 | !scope="col"|Identification Number Type
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13 | !scope="col"|Address/Phone
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14 | |----
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15 | |John D. Smith
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16 | |07/04/1960 10:15:02
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17 | |Male
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18 | |999999999
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19 | |Medical Record Number
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20 | |355 Maple Street <br>Williamsport, <br>Pennsylvania 17701 <br>570-837-8364
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21 | |----
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22 | |}
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23 |
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24 | Source for all data for this patient: John Fitzgerald, MD
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25 |
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26 | {| border="1"|
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27 | !colspan="6"|Problem List
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28 | |----
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29 | !scope="col"|Type
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30 | !scope="col"|ICD-9 Code
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31 | !scope="col"|Patient Problem
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32 | !scope="col"|Status
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33 | !scope="col"|Date Diagnosed
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34 | |----
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35 | |Diagnosis
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36 | |250.02
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37 | |Diabetes Mellitus, Type 2
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38 | |Active
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39 | |09/16/2009
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40 | |----
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41 | |Condition
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42 | |272.4
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43 | |Hyperlipidemia
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44 | |Active
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45 | |05/05/2002
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46 | |----
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47 | |Finding
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48 | |414.01
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49 | |Coronary Artery Disease (CAD)
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50 | |Chronic
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51 | |05/05/2002
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52 | |----
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53 | |Symptom
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54 | |401.9
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55 | |Hypertension, Essential
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56 | |Active
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57 | |05/05/2002
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58 | |----
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59 | |----
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60 | !scope="col"|Type
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61 | !scope="col"|SNOMED Code*
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62 | !scope="col"|Patient Problem
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63 | !scope="col"|Status
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64 | !scope="col"|Date Diagnosed
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65 | |----
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66 | |Disorder
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67 | |44054006
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68 | |Diabetes Mellitus, Type 2
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69 | |Active
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70 | |09/16/2009
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71 | |----
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72 | |Disorder
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73 | |55822004
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74 | |Hyperlipidemia
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75 | |Active
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76 | |05/05/2002
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77 | |----
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78 | |Disorder
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79 | |53741008
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80 | |Coronary Arteriosclerosis
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81 | |Chronic
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82 | |05/05/2002
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83 | |----
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84 | |Disorder
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85 | |59621000
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86 | |Essential Hypertension
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87 | |Active
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88 | |05/05/2002
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89 | |----
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90 | |}
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91 |
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92 | {| border="1"|
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93 | !colspan="10"|Medication List
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94 | |----
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95 | !scope="col"|RxNorm Code
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96 | !scope="col"|Product
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97 | !scope="col"|Generic Name
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98 | !scope="col"|Brand Name
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99 | !scope="col"|Strength
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100 | !scope="col"|Dose
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101 | !scope="col"|Route
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102 | !scope="col"|Frequency
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103 | !scope="col"|Date Started
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104 | !scope="col"|Status
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105 | |----
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106 | |205875
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107 | |Medication
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108 | |glyburide
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109 | |Diabeta
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110 | |2.5 mg
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111 | |1 Tablet
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112 | |PO
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113 | |Q AM
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114 | |09/16/2009
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115 | |Active
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116 | |----
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117 | |617314
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118 | |Medication
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119 | |atorvastatin calcium
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120 | |Lipitor
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121 | |10 mg
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122 | |1 Tablet
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123 | |PO
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124 | |Q Day
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125 | |05/05/2002
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126 | |Active
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127 | |----
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128 | |200801
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129 | |Medication
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130 | |furosemide
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131 | |Lasix
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132 | |20 mg
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133 | |1 Tablet
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134 | |PO
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135 | |BID
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136 | |05/05/2002
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137 | |Active
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138 | |----
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139 | |628958
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140 | |Medication
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141 | |potassium chloride
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142 | |Klor-Con
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143 | |10 mEq
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144 | |1 Tablet
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145 | |PO
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146 | |BID
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147 | |05/05/2002
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148 | |Active
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149 | |----
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150 | |}
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151 |
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152 | {| border="1"|
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153 | !colspan="5"|Medication Allergy List
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154 | |----
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155 | !scope="col"|Type
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156 | !scope="col"|SNOMED Code
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157 | !scope="col"|Medication/Agent
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158 | !scope="col"|Reaction
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159 | !scope="col"|Date Recorded
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160 | |----
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161 | |Drug Allergy
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162 | |293597001
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163 | |Codeine
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164 | |Hives
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165 | |06/27/1996
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166 | |----
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167 | |Drug Allergy
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168 | |294506009
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169 | |Ampicillin
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170 | |Diarrhea, nausea, vomiting
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171 | |03/15/1994
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172 | |----
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173 | |}
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174 |
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175 | {| border="1"|
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176 | !colspan="5"|Diagnostic Test Results
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177 | |----
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178 | !scope="col"|Type
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179 | !scope="col"|LOINC Code
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180 | !scope="col"|Test (Normal Range)
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181 | !scope="col"|Result
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182 | !scope="col"|Date Performed
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183 | |----
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184 | |Chemistry
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185 | |14771-0
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186 | |Fasting Blood Glucose (70100 mg/dl)
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187 | |178 mg/dl
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188 | |09/16/2009
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189 | |----
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190 | |Chemistry
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191 | |14682-9
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192 | |Creatinine (0.51.4 mg/dl)
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193 | |1.0 mg/dl
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194 | |09/16/2009
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195 | |----
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196 | |Chemistry
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197 | |14937-7
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198 | |BUN (730 mg/dl)
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199 | |18 mg/dl
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200 | |09/16/2009
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201 | |----
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202 | |Chemistry
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203 | |2951-2
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204 | |Sodium (135146 mg/dl)
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205 | |141 mg/dl
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206 | |09/16/2009
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207 | |----
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208 | |Chemistry
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209 | |2823-3
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210 | |Potassium (3.55.3 mg/dl)
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211 | |4.3 mg/dl
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212 | |09/16/2009
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213 | |----
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214 | |Chemistry
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215 | |14647-2
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216 | |Total cholesterol (<200 mg/dl)
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217 | |162 mg/dl
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218 | |09/16/2009
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219 | |----
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220 | |Chemistry
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221 | |14646-4
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222 | |HDL cholesterol (?40 mg/dl)
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223 | |43 mg/dl
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224 | |09/16/2009
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225 | |----
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226 | |Chemistry
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227 | |2089-1
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228 | |LDL cholesterol (<100 mg/dl)
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229 | |84 mg/dl
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230 | |09/16/2009
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231 | |----
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232 | |Chemistry
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233 | |14927-8
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234 | |Triglycerides (<150 mg/dl)
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235 | |177 mg/dl
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236 | |09/16/2009
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237 | |----
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238 | |Imaging
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239 | |24648-8
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240 | |Chest X-ray, PA
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241 | |No disease is seen in the<br>lung fields or pleura
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242 | |09/16/2009
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243 | |----
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244 | |}
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245 |
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