NIST-EP-Patient-3-Visit-1
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Test Procedure for §170.304.h Clinical Summaries APPROVED (Pending) Version 1.0 July 21, 2010
TD170.304.h.: Clinical summaries
- indicates alternative standard code per certification criteria
Clinical Summaries Test Data – Set #3|Office Visit #1 for Barbara Simpson
Patient | |||||
---|---|---|---|---|---|
Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
Barbara Simpson | 10/12/1956 19:47:01 | Female | 9688675266 | Medical Record Number | 996 Dalton Street, Fargo, North Dakota 54102 701-366-5534 |
“Source” for all data for this patient: Robert James, MD
Problem List | |||||
---|---|---|---|---|---|
Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
Diagnosis | 486 | Pneumonia | Active | 07/02/2010 | |
Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
Disorder | 233604007 | Pneumonia | Active | 07/02/2010 |
Medication List | |||||||||
---|---|---|---|---|---|---|---|---|---|
RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
308460 | Medication | azithromycin | Azithromycin | 250 mg | 1 Tablet | PO | QD | 07/02/2010 | Active |
Medication Allergy List | ||||
---|---|---|---|---|
Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
Drug Allergy | 91936005 | Penicillin | Rash and anaphylaxis | 06/10/2009 |
Drug Allergy | 91939003 | Sulfonamides | Hives, photosensitivity | 04/25/1988 |
Diagnostic Test Results | ||||
---|---|---|---|---|
Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
Imaging | 42272-5 | Chest X-ray, PA & Lateral | Bilateral Pneumonia | 07/02/2010 |
Cardiology | 34534-8 | Electrocardiogram | Sinus Tachycardia | 07/02/2010 |