* indicates alternative standard code per certification criteria 

Patient Summary Record Test Data – Set #1 

Patient 
        Name              Date/Time of Birth           Gender         Identification Number        Identification Number Type               Address/Phone 
John D. Smith              07/04/1960              Male                999999999                   Medical Record Number                 355 Maple Street 
                          10:15:02                                                                                                     Williamsport, 
                                                                                                                                        Pennsylvania  17701 
                                                                                                                                       570-837-8364 

“Source” for all data for this patient: John Fitzgerald, MD 

Problem List 
        Type                  ICD-9 Code                               Patient Problem                                 Status               Date Diagnosed 
Diagnosis                250.02                     Diabetes Mellitus, Type 2                                    Active                  09/16/2009 
Condition                272.4                      Hyperlipidemia                                                Active                 05/05/2002 
Finding                  414.01                     Coronary Artery Disease (CAD)                                 Chronic                05/05/2002 
Symptom                  401.9                      Hypertension, Essential                                       Active                 05/05/2002 

        Type               SNOMED Code*                                Patient Problem                                 Status               Date Diagnosed 
Disorder                 44054006                   Diabetes Mellitus, Type 2                                     Active                 09/16/2009 
Disorder                 55822004                   Hyperlipidemia                                                Active                 05/05/2002 
Disorder                 53741008                   Coronary Arteriosclerosis                                     Chronic                05/05/2002 
Disorder                 59621000                   Essential Hypertension                                        Active                 05/05/2002 

Medication List 
  RxNorm 
                    Product         Generic Name         Brand Name         Strength        Dose         Route      Frequency        Date Started        Status 
    Code 
205875            Medication       glyburide             Diabeta            2.5 mg       1 Tablet        PO         Q AM             09/16/2009         Active 
                                   atorvastatin 
617314            Medication                            Lipitor              10 mg       1 Tablet        PO         Q Day             05/05/2002        Active 
                                   calcium 

                                                                                                                      
 RxNorm 
                    Product         Generic Name         Brand Name         Strength        Dose         Route      Frequency        Date Started        Status 
    Code 
200801            Medication        furosemide           Lasix               20 mg        1 Tablet       PO         BID               05/05/2002        Active 
                                   potassium 
628958            Medication                            Klor-Con             10 mEq       1 Tablet       PO         BID               05/05/2002        Active 
                                   chloride 

Medication Allergy List 
          Type                       SNOMED Code                         Medication/Agent                        Reaction                     Date Recorded 
Drug Allergy                  293597001                             Codeine                             Hives                              06/27/1996 
Drug Allergy                  294506009                             Ampicillin                          Diarrhea, nausea, vomiting         03/15/1994 

Diagnostic Test Results 
         Type                  LOINC Code                       Test (Normal Range)                                Result                    Date Performed 
Chemistry                   14771-0                  Fasting Blood Glucose (70–100 mg/dl)               178 mg/dl                        09/16/2009 
Chemistry                   14682-9                  Creatinine (0.5–1.4 mg/dl)                         1.0 mg/dl                        09/16/2009 
Chemistry                   14937-7                  BUN (7–30 mg/dl)                                   18 mg/dl                         09/16/2009 
Chemistry                  2951-2                    Sodium (135–146 mg/dl)                             141 mg/dl                        09/16/2009 
Chemistry                  2823-3                    Potassium (3.5–5.3 mg/dl)                          4.3 mg/dl                        09/16/2009 
Chemistry                   14647-2                  Total cholesterol (<200 mg/dl)                     162 mg/dl                        09/16/2009 
Chemistry                   14646-4                  HDL cholesterol (?40 mg/dl)                        43 mg/dl                         09/16/2009 
Chemistry                  2089-1                    LDL cholesterol (<100 mg/dl)                       84 mg/dl                         09/16/2009 
Chemistry                   14927-8                  Triglycerides (<150 mg/dl)                         177 mg/dl                        09/16/2009 
                                                                                                       No disease is seen in the 
Imaging                     24648-8                   Chest X-ray, PA                                                                    09/16/2009 
                                                                                                       lung fields or pleura