| 1 | * indicates alternative standard code per certification criteria
|
|---|
| 2 |
|
|---|
| 3 | Patient Summary Record Test Data Set #1
|
|---|
| 4 |
|
|---|
| 5 | Patient
|
|---|
| 6 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
|---|
| 7 | John D. Smith|07/04/1960 10:15:02|Male|999999999|Medical Record Number|355 Maple Street <br>Williamsport, <br>Pennsylvania 17701 <br>570-837-8364
|
|---|
| 8 |
|
|---|
| 9 | Source for all data for this patient: John Fitzgerald, MD
|
|---|
| 10 |
|
|---|
| 11 | Problem List
|
|---|
| 12 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
|---|
| 13 | Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|09/16/2009
|
|---|
| 14 | Condition|272.4|Hyperlipidemia|Active|05/05/2002
|
|---|
| 15 | Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002
|
|---|
| 16 | Symptom|401.9|Hypertension, Essential|Active|05/05/2002
|
|---|
| 17 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
|---|
| 18 | Disorder|44054006|Diabetes Mellitus, Type 2|Active|09/16/2009
|
|---|
| 19 | Disorder|55822004|Hyperlipidemia|Active|05/05/2002
|
|---|
| 20 | Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002
|
|---|
| 21 | Disorder|59621000|Essential Hypertension|Active|05/05/2002
|
|---|
| 22 |
|
|---|
| 23 | Medication List
|
|---|
| 24 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
|---|
| 25 | 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|09/16/2009|Active
|
|---|
| 26 | 617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|05/05/2002|Active
|
|---|
| 27 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|05/05/2002|Active
|
|---|
| 28 | 628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|05/05/2002|Active
|
|---|
| 29 |
|
|---|
| 30 | Medication Allergy List
|
|---|
| 31 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
|---|
| 32 | Drug Allergy|293597001|Codeine|Hives|06/27/1996
|
|---|
| 33 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/15/1994
|
|---|
| 34 |
|
|---|
| 35 | Diagnostic Test Results
|
|---|
| 36 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
|---|
| 37 | Chemistry|14771-0|Fasting Blood Glucose (70100 mg/dl)|178 mg/dl|09/16/2009
|
|---|
| 38 | Chemistry|14682-9|Creatinine (0.51.4 mg/dl)|1.0 mg/dl|09/16/2009
|
|---|
| 39 | Chemistry|14937-7|BUN (730 mg/dl)|18 mg/dl|09/16/2009
|
|---|
| 40 | Chemistry|2951-2|Sodium (135146 mg/dl)|141 mg/dl|09/16/2009
|
|---|
| 41 | Chemistry|2823-3|Potassium (3.55.3 mg/dl)|4.3 mg/dl|09/16/2009
|
|---|
| 42 | Chemistry|14647-2|Total cholesterol (<200 mg/dl)|162 mg/dl|09/16/2009
|
|---|
| 43 | Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|43 mg/dl|09/16/2009
|
|---|
| 44 | Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|84 mg/dl|09/16/2009
|
|---|
| 45 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|177 mg/dl|09/16/2009
|
|---|
| 46 | Imaging|24648-8|Chest X-ray, PA|No disease is seen in the<br>lung fields or pleura |09/16/2009
|
|---|
| 47 |
|
|---|
