[1030] | 1 | Patient Summary Record Test Data Set #3
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| 2 |
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| 3 | {| border="1"|
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| 4 | !colspan="6"|Patient
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| 5 | |----
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| 6 | !scope="col"|Name
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| 7 | !scope="col"|Date/Time of Birth
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| 8 | !scope="col"|Gender
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| 9 | !scope="col"|Identification Number
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| 10 | !scope="col"|Identification Number Type
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| 11 | !scope="col"|Address/Phone
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| 12 | |----
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| 13 | |Jane Andrews
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| 14 | |05/12/1955 09:30:15
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| 15 | |Female
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| 16 | |9639275266
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| 17 | |Medical Record Number
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| 18 | |355 1st Street<br>Fargo,<br>North Dakota 54102<br>701-366-8364
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| 19 | |----
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| 20 | |}
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| 21 |
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| 22 | Source for all data for this patient: Robert James, MD
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| 23 |
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| 24 | {| border="1"|
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| 25 | !colspan="6"|Problem List
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| 26 | |----
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| 27 | !scope="col"|Type
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| 28 | !scope="col"|ICD-9 Code
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| 29 | !scope="col"|Patient Problem
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| 30 | !scope="col"|Status
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| 31 | !scope="col"|Date Diagnosed
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| 32 | |----
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| 33 | |Diagnosis
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| 34 | |486
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| 35 | |Pneumonia
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| 36 | |Resolved
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| 37 | |01/22/2010
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| 38 | |----
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| 39 | |Diagnosis
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| 40 | |496.0
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| 41 | |Chronic Obstructive Pulmonary Disease
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| 42 | |Chronic
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| 43 | |10/10/1999
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| 44 | |----
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| 45 | |----
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| 46 | !scope="col"|Type
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| 47 | !scope="col"|SNOMED Code*
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| 48 | !scope="col"|Patient Problem
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| 49 | !scope="col"|Status
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| 50 | !scope="col"|Date Diagnosed
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| 51 | |----
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| 52 | |Disorder
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| 53 | |233604007
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| 54 | |Pneumonia
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| 55 | |Resolved
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| 56 | |01/22/2010
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| 57 | |----
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| 58 | |Disorder
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| 59 | |13645005
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| 60 | |Chronic Obstructive Lung Disease
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| 61 | |Chronic
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| 62 | |10/10/1999
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| 63 | |----
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| 64 | |}
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| 65 |
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| 66 | {| border="1"|
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| 67 | !colspan="10"|Medication List
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| 68 | |----
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| 69 | !scope="col"|RxNorm Code
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| 70 | !scope="col"|Product
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| 71 | !scope="col"|Generic Name
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| 72 | !scope="col"|Brand Name
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| 73 | !scope="col"|Strength
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| 74 | !scope="col"|Dose
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| 75 | !scope="col"|Route
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| 76 | !scope="col"|Frequency
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| 77 | !scope="col"|Date Started
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| 78 | !scope="col"|Status
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| 79 | |----
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| 80 | |308460
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| 81 | |Medication
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| 82 | |azithromycin
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| 83 | |Azithromycin
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| 84 | |250 mg
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| 85 | |1 Tablet
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| 86 | |PO
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| 87 | |QD
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| 88 | |01/22/2010
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| 89 | |No Longer Active
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| 90 | |----
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| 91 | |836370
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| 92 | |Medication
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| 93 | |ipratropium bromide monhydrate
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| 94 | |Atrovent Inhaler
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| 95 | |18 mcg/puff
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| 96 | |2 Puffs
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| 97 | |Inhaled
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| 98 | |QID
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| 99 | |10/10/1999
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| 100 | |Active
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| 101 | |----
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| 102 | |630208
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| 103 | |Medication
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| 104 | |albuterol sulfate
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| 105 | |Albuterol Inhaler
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| 106 | |2.5 mg/3ml
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| 107 | |2 Puffs
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| 108 | |Inhaled
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| 109 | |Q 4 PRN
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| 110 | |10/10/1999
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| 111 | |Active
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| 112 | |----
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| 113 | |}
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| 114 |
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| 115 | {| border="1"|
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| 116 | !colspan="5"|Medication Allergy List
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| 117 | |----
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| 118 | !scope="col"|Type
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| 119 | !scope="col"|SNOMED Code
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| 120 | !scope="col"|Medication/Agent
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| 121 | !scope="col"|Reaction
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| 122 | !scope="col"|Date Recorded
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| 123 | |----
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| 124 | |Drug Allergy
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| 125 | |91936005
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| 126 | |Penicillin
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| 127 | |Rash and anaphylaxis
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| 128 | |06/10/2009
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| 129 | |----
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| 130 | |Drug Allergy
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| 131 | |91939003
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| 132 | |Sulfonamides
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| 133 | |Hives, photosensitivity
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| 134 | |04/25/1988
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| 135 | |----
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| 136 | |}
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| 137 |
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| 138 | {| border="1"|
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| 139 | !colspan="5"|Diagnostic Test Results
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| 140 | |----
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| 141 | !scope="col"|Type
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| 142 | !scope="col"|LOINC Code
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| 143 | !scope="col"|Test (Normal Range)
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| 144 | !scope="col"|Result
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| 145 | !scope="col"|Date Performed
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| 146 | |----
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| 147 | |42272-5
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| 148 | |Imaging
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| 149 | |Chest X-ray, PA & Lateral
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| 150 | |Hyperinflated lungs with<br>flattened diaphragm and<br>central pulmonary artery<br>enlargement
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| 151 | |02/15/2010
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| 152 | |----
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| 153 | |Hematology
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| 154 | |718-7
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| 155 | |Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)
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| 156 | |16 g/dl
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| 157 | |12/22/2009
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| 158 | |----
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| 159 | |Hematology
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| 160 | |4544-3
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| 161 | |Hematocrit (male: 40-54%<br>female: 36-48%)
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| 162 | | 45%
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| 163 | |12/22/2009
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| 164 | |----
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| 165 | |Cardiology
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| 166 | |34534-8
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| 167 | |Electrocardiogram
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| 168 | |Normal Sinus Rhythm
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| 169 | |12/22/2009
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| 170 | |----
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