NIST-EP-Patient-4-Visit-1
From VistApedia
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 #4|Office Visit #1 for Susan Ellerby
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Susan Ellerby | 12/08/1963 21:54:24 | Female | 925377799 | Medical Record Number | 483 Powell Street, Shawville, Pennsylvania 16873 814-645-9475 |
“Source” for all data for this patient: Dorcas Wayne, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Condition | 272.4 | Hyperlipidemia | Active | 07/06/2010 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 55822004 | Hyperlipidemia | Active | 07/06/2010 | |
| Medication List | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
| 617314 | Medication | atorvastatin calcium | Lipitor | 10 mg | 1 Tablet | PO | Q Day | 07/06/2010 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 91936005 | Penicillin | Rash and anaphylaxis | 05/22/1998 |
| Drug Allergy | 293597001 | Codeine | Hives | 02/17/1992 |
| Diagnostic Test Results | ||||
|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
| Chemistry | 14647-2 | Total cholesterol (<200 mg/dl) | 279 mg/dl | 07/06/2010 |
| Chemistry | 14646-4 | HDL cholesterol (?40 mg/dl) | 89 mg/dl | 07/06/2010 |
| Chemistry | 2089-1 | LDL cholesterol (<100 mg/dl) | 190 mg/dl | 07/06/2010 |
| Chemistry | 14927-8 | Triglycerides (<150 mg/dl) | 187 mg/dl | 07/06/2010 |
