| 1 | * indicates alternative standard code per certification criteria
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| 2 |
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| 3 | Patient Summary Record Test Data Set #1
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| 4 |
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| 5 | Patient
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| 6 | Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
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| 7 | John D. Smith 07/04/1960 Male 999999999 Medical Record Number 355 Maple Street
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| 8 | 10:15:02 Williamsport,
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| 9 | Pennsylvania 17701
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| 10 | 570-837-8364
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| 11 |
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| 12 | Source for all data for this patient: John Fitzgerald, MD
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| 13 |
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| 14 | Problem List
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| 15 | Type ICD-9 Code Patient Problem Status Date Diagnosed
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| 16 | Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 09/16/2009
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| 17 | Condition 272.4 Hyperlipidemia Active 05/05/2002
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| 18 | Finding 414.01 Coronary Artery Disease (CAD) Chronic 05/05/2002
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| 19 | Symptom 401.9 Hypertension, Essential Active 05/05/2002
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| 20 |
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| 21 | Type SNOMED Code* Patient Problem Status Date Diagnosed
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| 22 | Disorder 44054006 Diabetes Mellitus, Type 2 Active 09/16/2009
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| 23 | Disorder 55822004 Hyperlipidemia Active 05/05/2002
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| 24 | Disorder 53741008 Coronary Arteriosclerosis Chronic 05/05/2002
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| 25 | Disorder 59621000 Essential Hypertension Active 05/05/2002
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| 26 |
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| 27 | Medication List
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| 28 | RxNorm
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| 29 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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| 30 | Code
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| 31 | 205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 09/16/2009 Active
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| 32 | atorvastatin
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| 33 | 617314 Medication Lipitor 10 mg 1 Tablet PO Q Day 05/05/2002 Active
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| 34 | calcium
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| 35 |
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| 36 |
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| 37 | RxNorm
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| 38 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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| 39 | Code
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| 40 | 200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 05/05/2002 Active
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| 41 | potassium
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| 42 | 628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 05/05/2002 Active
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| 43 | chloride
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| 44 |
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| 45 | Medication Allergy List
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| 46 | Type SNOMED Code Medication/Agent Reaction Date Recorded
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| 47 | Drug Allergy 293597001 Codeine Hives 06/27/1996
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| 48 | Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/15/1994
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| 49 |
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| 50 | Diagnostic Test Results
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| 51 | Type LOINC Code Test (Normal Range) Result Date Performed
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| 52 | Chemistry 14771-0 Fasting Blood Glucose (70100 mg/dl) 178 mg/dl 09/16/2009
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| 53 | Chemistry 14682-9 Creatinine (0.51.4 mg/dl) 1.0 mg/dl 09/16/2009
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| 54 | Chemistry 14937-7 BUN (730 mg/dl) 18 mg/dl 09/16/2009
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| 55 | Chemistry 2951-2 Sodium (135146 mg/dl) 141 mg/dl 09/16/2009
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| 56 | Chemistry 2823-3 Potassium (3.55.3 mg/dl) 4.3 mg/dl 09/16/2009
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| 57 | Chemistry 14647-2 Total cholesterol (<200 mg/dl) 162 mg/dl 09/16/2009
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| 58 | Chemistry 14646-4 HDL cholesterol (?40 mg/dl) 43 mg/dl 09/16/2009
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| 59 | Chemistry 2089-1 LDL cholesterol (<100 mg/dl) 84 mg/dl 09/16/2009
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| 60 | Chemistry 14927-8 Triglycerides (<150 mg/dl) 177 mg/dl 09/16/2009
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| 61 | No disease is seen in the
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| 62 | Imaging 24648-8 Chest X-ray, PA 09/16/2009
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| 63 | lung fields or pleura
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