Patient Summary Record Test Data – Set #3

{| border="1"|
!colspan="6"|Patient
|----
!scope="col"|Name
!scope="col"|Date/Time of Birth
!scope="col"|Gender
!scope="col"|Identification Number
!scope="col"|Identification Number Type
!scope="col"|Address/Phone
|----
|Lorraine Blevins
|04/16/1957<br>20:15:35
|Female
|967385998
|Medical Record Number
|1020 Stuart Street<br>Morton, <br>Illinois  61550<br> 309-374-8938
|----
|}

“Source” for all data for this patient: Louis Randolph, MD

{| border="1"|
!colspan="6"|Problem List
|----
!scope="col"|Type
!scope="col"|ICD-9 Code
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Diagnosis
|715.35
|Right hip osteoarthritis
|Resolved
|02/12/2010
|----
|Finding
|414.01
|Coronary Artery Disease (CAD)
|Chronic
|05/05/2002
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|239872002
|Right hip osteoarthritis
|Resolved
|02/12/2010
|----
|Disorder
|53741008
|Coronary Arteriosclerosis
|Chronic
|05/05/2002
|----
|}

{| border="1"|
!colspan="10"|Medication List
|----
!scope="col"|RxNorm Code
!scope="col"|Product
!scope="col"|Generic Name
!scope="col"|Brand Name
!scope="col"|Strength
!scope="col"|Dose
!scope="col"|Route
!scope="col"|Frequency
!scope="col"|Date Started
!scope="col"|Status
|----
|855320
|Medication
|warfarin
|Coumadin
|3 mg
|1 Tablet
|PO
|QD
|02/15/2010
|Active
|----
|209613
|Medication
|bisacodyl
|Dulcolax
|5 mg
|1 Tablet
|PO
|QD
|02/15/2010
|Active
|----
|309362
|Medication
|clopidogrel
|Plavix
|75 mg
|1 Tablet
|PO
|QD
|05/15/2002
|Active
|----
|197361
|Medication
|amlodipine
|Norvasc
|5 mg
|1 Tablet
|PO
|QD
|07/15/2009
|Active
|----
|}

{| border="1"|
!colspan="5"|Medication Allergy List
|----
!scope="col"|Type
!scope="col"|SNOMED Code
!scope="col"|Medication/Agent
!scope="col"|Reaction
!scope="col"|Date Recorded
|----
|Drug Allergy
|91939003
|Sulfonamides
|Hives, photosensitivity
|06/06/1998
|----
|Drug Allergy
|294506009
|Ampicillin
|Diarrhea, nausea, vomiting
|04/25/1994
|----
|}

{| border="1"|
!colspan="5"|Diagnostic Test Results
|----
!scope="col"|Type
!scope="col"|LOINC Code
!scope="col"|Test (Normal Range)
!scope="col"|Result
!scope="col"|Date Performed
|----
|Imaging
|37721-8
|X-ray, 2 views, Right Hip
|Subchondral sclerosis,<br> increased density in<br>subchondral bone
|02/12/2010
|----
|Imaging
|24648-8
|Chest X-ray, PA
|No disease is seen in<br> the lung fields or pleura
|06/05/2009
|----
|Hematology
|718-7
|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)
|11.2 g/dl
|06/05/2009
|----
|Hematology
|4544-3
|Hematocrit (male: 40-54% <br>female: 36-48%)
|34%
|06/05/2009
|----
|Coagulation
|34714-6
|Prothrombin Time/ International Normalized Ratio (PT/INR)<br>(2.5 – 3.5) 
|3.1
|06/05/2009
|----
|}

{| border="1"|
!colspan="5"|Procedure List
|----
!scope="col"|Type
!scope="col"|ICD-9 Code
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Surgical
|81.51
|Total Hip Replacement, Right
|Completed
|02/14/2010
|----
|Cardiac
|37.21
|Cardiac catheterization
|Completed
|05/05/2002
|----
|----
!scope="col"|Type
!scope="col"|CPT Code*
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Surgical
|27130
|Total Hip Replacement, Right
|Completed
|02/14/2010
|----
|Cardiac
|93501
|Cardiac catheterization
|Completed
|05/05/2002
|----