NIST-EP-Patient-3-Visit-2

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 #2 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	496.0	Chronic Obstructive Pulmonary Disease	Chronic	02/10/2010
Type	SNOMED Code*	Patient Problem	Status	Date Diagnosed
Disorder	13645005	Chronic Obstructive Lung Disease	Chronic	02/10/2010

Medication List
RxNorm Code	Product	Generic Name	Brand Name	Strength	Dose	Route	Frequency	Date Started	Status
836370	Medication	ipratropium bromide monohydrate	Atrovent Inhaler	18 mcg/puff	2 Puffs	Inhaled	QID	02/10/2010	Active
630208	Medication	albuterol sulfate	Albuterol Inhaler	2.5 mg/3ml	2 Puffs	Inhaled	Q 4 hours as needed	02/10/2010	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	Hyperinflated lungs with flattened diaphragm and central pulmonary artery enlargement	02/10/2010
Hematology	718-7	Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)	16 g/dl	02/10/2010
Hematology	4544-3	Hematocrit (male: 40-54% female: 36-48%)	45%	02/10/2010

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