Patient Summary Record Test Data – Set #3 

Patient 
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone 
Jane Andrews|05/12/1955 09:30:15|Female|9639275266|Medical Record Number|355 1st Street<br>Fargo,<br>North Dakota 54102<br>701-366-8364 

“Source” for all data for this patient: Robert James, MD 

Problem List 
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed 
Diagnosis|486|Pneumonia|Resolved|01/22/2010 
Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|10/10/1999 
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed 
Disorder|233604007|Pneumonia|Resolved|01/22/2010 
Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|10/10/1999 

Medication List 
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status 
308460|Medication|azithromycin|Azithromycin|250 mg|1 Tablet|PO|QD|01/22/2010|No Longer Active
836370|Medication|ipratropium bromide monhydrate|Atrovent Inhaler|18 mcg/puff|2 Puffs|Inhaled|QID|10/10/1999|Active 
630208|Medication|albuterol sulfate|Albuterol Inhaler|2.5 mg/3ml|2 Puffs|Inhaled|Q 4 PRN|10/10/1999|Active 

Medication Allergy List 
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded 
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|06/10/2009 
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988 

Diagnostic Test Results 
Type|LOINC Code|Test (Normal Range)|Result|Date Performed 
42272-5|Imaging|Chest X-ray, PA & Lateral|Hyperinflated lungs with<br>flattened diaphragm and<br>central pulmonary artery<br>enlargement|02/15/2010 
Hematology|718-7|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)|16 g/dl|12/22/2009 
Hematology|4544-3|Hematocrit (male: 40-54%<br>female: 36-48%)| 45%|12/22/2009 
Cardiology|34534-8|Electrocardiogram|Normal Sinus Rhythm|12/22/2009