| [1019] | 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 Male 999999999 Medical Record Number 355 Maple Street
|
|---|
| 8 | 10:15:02 Williamsport,
|
|---|
| 9 | Pennsylvania 17701
|
|---|
| 10 | 570-837-8364
|
|---|
| 11 |
|
|---|
| 12 | Source for all data for this patient: John Fitzgerald, MD
|
|---|
| 13 |
|
|---|
| 14 | Problem List
|
|---|
| 15 | Type ICD-9 Code Patient Problem Status Date Diagnosed
|
|---|
| 16 | Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 09/16/2009
|
|---|
| 17 | Condition 272.4 Hyperlipidemia Active 05/05/2002
|
|---|
| 18 | Finding 414.01 Coronary Artery Disease (CAD) Chronic 05/05/2002
|
|---|
| 19 | Symptom 401.9 Hypertension, Essential Active 05/05/2002
|
|---|
| 20 |
|
|---|
| 21 | Type SNOMED Code* Patient Problem Status Date Diagnosed
|
|---|
| 22 | Disorder 44054006 Diabetes Mellitus, Type 2 Active 09/16/2009
|
|---|
| 23 | Disorder 55822004 Hyperlipidemia Active 05/05/2002
|
|---|
| 24 | Disorder 53741008 Coronary Arteriosclerosis Chronic 05/05/2002
|
|---|
| 25 | Disorder 59621000 Essential Hypertension Active 05/05/2002
|
|---|
| 26 |
|
|---|
| 27 | Medication List
|
|---|
| 28 | RxNorm
|
|---|
| 29 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
|---|
| 30 | Code
|
|---|
| 31 | 205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 09/16/2009 Active
|
|---|
| 32 | atorvastatin
|
|---|
| 33 | 617314 Medication Lipitor 10 mg 1 Tablet PO Q Day 05/05/2002 Active
|
|---|
| 34 | calcium
|
|---|
| 35 |
|
|---|
| 36 |
|
|---|
| 37 | RxNorm
|
|---|
| 38 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
|---|
| 39 | Code
|
|---|
| 40 | 200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 05/05/2002 Active
|
|---|
| 41 | potassium
|
|---|
| 42 | 628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 05/05/2002 Active
|
|---|
| 43 | chloride
|
|---|
| 44 |
|
|---|
| 45 | Medication Allergy List
|
|---|
| 46 | Type SNOMED Code Medication/Agent Reaction Date Recorded
|
|---|
| 47 | Drug Allergy 293597001 Codeine Hives 06/27/1996
|
|---|
| 48 | Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/15/1994
|
|---|
| 49 |
|
|---|
| 50 | Diagnostic Test Results
|
|---|
| 51 | Type LOINC Code Test (Normal Range) Result Date Performed
|
|---|
| 52 | Chemistry 14771-0 Fasting Blood Glucose (70100 mg/dl) 178 mg/dl 09/16/2009
|
|---|
| 53 | Chemistry 14682-9 Creatinine (0.51.4 mg/dl) 1.0 mg/dl 09/16/2009
|
|---|
| 54 | Chemistry 14937-7 BUN (730 mg/dl) 18 mg/dl 09/16/2009
|
|---|
| 55 | Chemistry 2951-2 Sodium (135146 mg/dl) 141 mg/dl 09/16/2009
|
|---|
| 56 | Chemistry 2823-3 Potassium (3.55.3 mg/dl) 4.3 mg/dl 09/16/2009
|
|---|
| 57 | Chemistry 14647-2 Total cholesterol (<200 mg/dl) 162 mg/dl 09/16/2009
|
|---|
| 58 | Chemistry 14646-4 HDL cholesterol (?40 mg/dl) 43 mg/dl 09/16/2009
|
|---|
| 59 | Chemistry 2089-1 LDL cholesterol (<100 mg/dl) 84 mg/dl 09/16/2009
|
|---|
| 60 | Chemistry 14927-8 Triglycerides (<150 mg/dl) 177 mg/dl 09/16/2009
|
|---|
| 61 | No disease is seen in the
|
|---|
| 62 | Imaging 24648-8 Chest X-ray, PA 09/16/2009
|
|---|
| 63 | lung fields or pleura
|
|---|
