1 | Patient Summary Record Test Data Set #4
|
---|
2 |
|
---|
3 | {| border="1"|
|
---|
4 | !colspan="6"|Patient
|
---|
5 | |----
|
---|
6 | !scope="col"|Name
|
---|
7 | !scope="col"|Date/Time of Birth
|
---|
8 | !scope="col"|Gender
|
---|
9 | !scope="col"|Identification Number
|
---|
10 | !scope="col"|Identification Number Type
|
---|
11 | !scope="col"|Address/Phone
|
---|
12 | |----
|
---|
13 | |Paul Jackson
|
---|
14 | |03/08/1962<br>14:25:50
|
---|
15 | |Male
|
---|
16 | |998777349
|
---|
17 | |Medical Record Number
|
---|
18 | |754 Samuel Street,<br>Blanchard, <br> Oklahoma 73010 <br>405-228-9292
|
---|
19 | |----
|
---|
20 | |}
|
---|
21 |
|
---|
22 | Source for all data for this patient: Mary Pfiffer, MD
|
---|
23 |
|
---|
24 | {| border="1"|
|
---|
25 | !colspan="6"|Problem List
|
---|
26 | |----
|
---|
27 | !scope="col"|Type
|
---|
28 | !scope="col"|ICD-9 Code
|
---|
29 | !scope="col"|Patient Problem
|
---|
30 | !scope="col"|Status
|
---|
31 | !scope="col"|Date Diagnosed
|
---|
32 | |----
|
---|
33 | |Diagnosis
|
---|
34 | |410.90
|
---|
35 | |Acute Myocardial Infarction
|
---|
36 | |Resolved
|
---|
37 | |07/12/2010
|
---|
38 | |----
|
---|
39 | |Finding
|
---|
40 | |414.01
|
---|
41 | |Coronary Artery Disease (CAD)
|
---|
42 | |Chronic
|
---|
43 | |07/05/2000
|
---|
44 | |----
|
---|
45 | |----
|
---|
46 | !scope="col"|Type
|
---|
47 | !scope="col"|SNOMED Code*
|
---|
48 | !scope="col"|Patient Problem
|
---|
49 | !scope="col"|Status
|
---|
50 | !scope="col"|Date Diagnosed
|
---|
51 | |----
|
---|
52 | |Disorder
|
---|
53 | |57054005
|
---|
54 | |Acute Myocardial Infarction
|
---|
55 | |Resolved
|
---|
56 | |07/12/2010
|
---|
57 | |----
|
---|
58 | |Disorder
|
---|
59 | |53741008
|
---|
60 | |Coronary Arteriosclerosis
|
---|
61 | |Chronic
|
---|
62 | |07/05/2000
|
---|
63 | |----
|
---|
64 | |}
|
---|
65 |
|
---|
66 | {| border="1"|
|
---|
67 | !colspan="10"|Medication List
|
---|
68 | |----
|
---|
69 | !scope="col"|RxNorm Code
|
---|
70 | !scope="col"|Product
|
---|
71 | !scope="col"|Generic Name
|
---|
72 | !scope="col"|Brand Name
|
---|
73 | !scope="col"|Strength
|
---|
74 | !scope="col"|Dose
|
---|
75 | !scope="col"|Route
|
---|
76 | !scope="col"|Frequency
|
---|
77 | !scope="col"|Date Started
|
---|
78 | !scope="col"|Status
|
---|
79 | |----
|
---|
80 | |198039
|
---|
81 | |Medication
|
---|
82 | |nitroglycerin
|
---|
83 | |Nitroglycerin
|
---|
84 | |400 mcg
|
---|
85 | |1 Tablet
|
---|
86 | |SL
|
---|
87 | |As needed
|
---|
88 | |07/15/2010
|
---|
89 | |Active
|
---|
90 | |----
|
---|
91 | |309362
|
---|
92 | |Medication
|
---|
93 | |clopidogrel
|
---|
94 | |Plavix
|
---|
95 | |75 mg
|
---|
96 | |1 Tablet
|
---|
97 | |PO
|
---|
98 | |QD
|
---|
99 | |07/05/2000
|
---|
100 | |Active
|
---|
101 | |----
|
---|
102 | |197361
|
---|
103 | |Medication
|
---|
104 | |amlodipine
|
---|
105 | |Norvasc
|
---|
106 | |5 mg
|
---|
107 | |1 Tablet
|
---|
108 | |PO
|
---|
109 | |QD
|
---|
110 | |07/05/2000
|
---|
111 | |Active
|
---|
112 | |----
|
---|
113 | |}
|
---|
114 |
|
---|
115 | {| border="1"|
|
---|
116 | !colspan="5"|Medication Allergy List
|
---|
117 | |----
|
---|
118 | !scope="col"|Type
|
---|
119 | !scope="col"|SNOMED Code
|
---|
120 | !scope="col"|Medication/Agent
|
---|
121 | !scope="col"|Reaction
|
---|
122 | !scope="col"|Date Recorded
|
---|
123 | |----
|
---|
124 | |Drug Allergy
|
---|
125 | |91936005
|
---|
126 | |Penicillin
|
---|
127 | |Rash and anaphylaxis
|
---|
128 | |07/12/2010
|
---|
129 | |----
|
---|
130 | |Drug Allergy
|
---|
131 | |294506009
|
---|
132 | |Ampicillin
|
---|
133 | |Diarrhea, nausea, vomiting
|
---|
134 | |03/28/2000
|
---|
135 | |----
|
---|
136 | |}
|
---|
137 |
|
---|
138 | {| border="1"|
|
---|
139 | !colspan="5"|Diagnostic Test Results
|
---|
140 | |----
|
---|
141 | !scope="col"|Type
|
---|
142 | !scope="col"|LOINC Code
|
---|
143 | !scope="col"|Test (Normal Range)
|
---|
144 | !scope="col"|Result
|
---|
145 | !scope="col"|Date Performed
|
---|
146 | |----
|
---|
147 | |Chemistry
|
---|
148 | |14647-2
|
---|
149 | |Total cholesterol (<200 mg/dl)
|
---|
150 | |220 mg/dl
|
---|
151 | |07/15/2010
|
---|
152 | |----
|
---|
153 | |Chemistry
|
---|
154 | |14927-8
|
---|
155 | |Triglycerides (<150 mg/dl)
|
---|
156 | |165 mg/dl
|
---|
157 | |07/15/2010
|
---|
158 | |----
|
---|
159 | |Imaging
|
---|
160 | |42272-5
|
---|
161 | |Chest X-ray, PA & Lateral
|
---|
162 | |The heart outline is slightly <br>enlarged, the hilar and <br>mediastinal vessels are of <br>normal appearance
|
---|
163 | |07/15/2010
|
---|
164 | |----
|
---|
165 | |Hematology
|
---|
166 | |718-7
|
---|
167 | |Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)
|
---|
168 | |12.8 g/dl
|
---|
169 | |2/18/2010
|
---|
170 | |----
|
---|
171 | |Hematology
|
---|
172 | |4544-3
|
---|
173 | |Hematocrit (male: 40-54% female: 36-48%)
|
---|
174 | |44%
|
---|
175 | |2/18/2010
|
---|
176 | |----
|
---|
177 | |}
|
---|
178 |
|
---|
179 | {| border="1"|
|
---|
180 | !colspan="5"|Procedure List
|
---|
181 | |----
|
---|
182 | !scope="col"|Type
|
---|
183 | !scope="col"|ICD-9 Code
|
---|
184 | !scope="col"|Procedure
|
---|
185 | !scope="col"|Status
|
---|
186 | !scope="col"|Date Performed
|
---|
187 | |----
|
---|
188 | |Cardiac
|
---|
189 | |00.66
|
---|
190 | |Percutaneous transluminal coronary angioplasty
|
---|
191 | |Completed
|
---|
192 | |07/15/2010
|
---|
193 | |----
|
---|
194 | |----
|
---|
195 | !scope="col"|Type
|
---|
196 | !scope="col"|CPT Code*
|
---|
197 | !scope="col"|Procedure
|
---|
198 | !scope="col"|Status
|
---|
199 | !scope="col"|Date Performed
|
---|
200 | |----
|
---|
201 | |Cardiac
|
---|
202 | |92982
|
---|
203 | |Percutaneous transluminal coronary angioplasty
|
---|
204 | |Completed
|
---|
205 | |07/15/2010
|
---|
206 | |----
|
---|