[1024] | 1 | Patient Summary Record Test Data Set #4
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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 | |Paul Jackson
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| 14 | |03/08/1962<br>14:25:50
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| 15 | |Male
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| 16 | |998777349
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| 17 | |Medical Record Number
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| 18 | |754 Samuel Street,<br>Blanchard, <br> Oklahoma 73010 <br>405-228-9292
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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: Mary Pfiffer, 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 | |410.90
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| 35 | |Acute Myocardial Infarction
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| 36 | |Resolved
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| 37 | |07/12/2010
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| 38 | |----
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| 39 | |Finding
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| 40 | |414.01
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| 41 | |Coronary Artery Disease (CAD)
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| 42 | |Chronic
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| 43 | |07/05/2000
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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 | |57054005
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| 54 | |Acute Myocardial Infarction
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| 55 | |Resolved
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| 56 | |07/12/2010
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| 57 | |----
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| 58 | |Disorder
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| 59 | |53741008
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| 60 | |Coronary Arteriosclerosis
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| 61 | |Chronic
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| 62 | |07/05/2000
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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 | |198039
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| 81 | |Medication
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| 82 | |nitroglycerin
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| 83 | |Nitroglycerin
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| 84 | |400 mcg
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| 85 | |1 Tablet
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| 86 | |SL
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| 87 | |As needed
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| 88 | |07/15/2010
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| 89 | |Active
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| 90 | |----
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| 91 | |309362
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| 92 | |Medication
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| 93 | |clopidogrel
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| 94 | |Plavix
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| 95 | |75 mg
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| 96 | |1 Tablet
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| 97 | |PO
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| 98 | |QD
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| 99 | |07/05/2000
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| 100 | |Active
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| 101 | |----
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| 102 | |197361
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| 103 | |Medication
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| 104 | |amlodipine
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| 105 | |Norvasc
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| 106 | |5 mg
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| 107 | |1 Tablet
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| 108 | |PO
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| 109 | |QD
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| 110 | |07/05/2000
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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 | |07/12/2010
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| 129 | |----
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| 130 | |Drug Allergy
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| 131 | |294506009
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| 132 | |Ampicillin
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| 133 | |Diarrhea, nausea, vomiting
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| 134 | |03/28/2000
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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 | |Chemistry
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| 148 | |14647-2
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| 149 | |Total cholesterol (<200 mg/dl)
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| 150 | |220 mg/dl
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| 151 | |07/15/2010
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| 152 | |----
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| 153 | |Chemistry
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| 154 | |14927-8
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| 155 | |Triglycerides (<150 mg/dl)
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| 156 | |165 mg/dl
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| 157 | |07/15/2010
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| 158 | |----
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| 159 | |Imaging
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| 160 | |42272-5
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| 161 | |Chest X-ray, PA & Lateral
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| 162 | |The heart outline is slightly <br>enlarged, the hilar and <br>mediastinal vessels are of <br>normal appearance
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| 163 | |07/15/2010
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| 164 | |----
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| 165 | |Hematology
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| 166 | |718-7
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| 167 | |Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)
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| 168 | |12.8 g/dl
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| 169 | |2/18/2010
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| 170 | |----
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| 171 | |Hematology
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| 172 | |4544-3
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| 173 | |Hematocrit (male: 40-54% female: 36-48%)
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| 174 | |44%
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| 175 | |2/18/2010
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| 176 | |----
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| 177 | |}
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| 178 |
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| 179 | {| border="1"|
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| 180 | !colspan="5"|Procedure List
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| 181 | |----
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| 182 | !scope="col"|Type
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| 183 | !scope="col"|ICD-9 Code
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| 184 | !scope="col"|Procedure
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| 185 | !scope="col"|Status
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| 186 | !scope="col"|Date Performed
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| 187 | |----
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| 188 | |Cardiac
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| 189 | |00.66
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| 190 | |Percutaneous transluminal coronary angioplasty
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| 191 | |Completed
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| 192 | |07/15/2010
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| 193 | |----
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| 194 | |----
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| 195 | !scope="col"|Type
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| 196 | !scope="col"|CPT Code*
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| 197 | !scope="col"|Procedure
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| 198 | !scope="col"|Status
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| 199 | !scope="col"|Date Performed
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| 200 | |----
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| 201 | |Cardiac
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| 202 | |92982
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| 203 | |Percutaneous transluminal coronary angioplasty
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| 204 | |Completed
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| 205 | |07/15/2010
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| 206 | |----
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