NIST Ambulatory Test Patient 2 - Revision history

NeilArmstrong: Added glossary link to Record~

2012-04-07T13:08:31Z

Added glossary link to Record~

← Older revision		Revision as of 13:08, 7 April 2012
Line 1:		Line 1:
	Test Procedure for §170.304.~~i Exchange Clinical Information and Patient Summary Record~~		Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary [[Record~\|Record]]
	APPROVED (Pending) Version 1.0 July 21, 2010		APPROVED (Pending) Version 1.0 July 21, 2010

	Patient Summary Record Test Data – Set #2		Patient Summary [[Record~\|Record]] Test Data – Set #2

	{\| border="1"\|		{\| border="1"\|
Line 18:		Line 18:
	\|Male		\|Male
	\|9813466798		\|9813466798
	\|Medical Record Number		\|Medical [[Record~\|Record]] Number
	\|355 Elm Street<br>Morton,<br>Illinois 61550<br>309-377-8365		\|355 Elm Street<br>Morton,<br>Illinois 61550<br>309-377-8365
	\|----		\|----
Line 112:		Line 112:
	!scope="col"\|Medication/Agent		!scope="col"\|Medication/Agent
	!scope="col"\|Reaction		!scope="col"\|Reaction
	!scope="col"\|Date ~~Recorded~~		!scope="col"\|Date [[Record~\|Record]]ed
	\|----		\|----
	\|Drug [[Allergy~\|Allergy]]		\|Drug [[Allergy~\|Allergy]]

NeilArmstrong: Added glossary link to Allergy~

2012-02-22T08:30:45Z

Added glossary link to Allergy~

← Older revision		Revision as of 08:30, 22 February 2012
Line 106:		Line 106:

	{\| border="1"\|		{\| border="1"\|
	!colspan="5"\|Medication Allergy List		!colspan="5"\|Medication [[Allergy~\|Allergy]] List
	\|----		\|----
	!scope="col"\|Type		!scope="col"\|Type
Line 114:		Line 114:
	!scope="col"\|Date Recorded		!scope="col"\|Date Recorded
	\|----		\|----
	\|Drug Allergy		\|Drug [[Allergy~\|Allergy]]
	\|91936005		\|91936005
	\|Penicillin		\|Penicillin
Line 120:		Line 120:
	\|08/10/2008		\|08/10/2008
	\|----		\|----
	\|Drug Allergy		\|Drug [[Allergy~\|Allergy]]
	\|293620004		\|293620004
	\|Indomethacin		\|Indomethacin

DaveMishler: initial data entry

2010-12-01T01:49:14Z

initial data entry

New page

Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary Record
APPROVED (Pending) Version 1.0 July 21, 2010

Patient Summary Record Test Data – Set #2

{| 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
|----
|Ralph Johnson
|06/28/1984 13:20:10
|Male
|9813466798
|Medical Record Number
|355 Elm Street Morton, Illinois 61550 309-377-8365
|----
|}

“Source” for all data for this patient: Carl Roberts, 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
|493.00
|Asthma, unspecified
|Active
|12/22/2009
|----
|Diagnosis
|250.02
|Diabetes Mellitus, Type 2
|Active
|08/10/2008
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|195967001
|Asthma
|Active
|12/22/2009
|----
|Disorder
|44054006
|Diabetes Mellitus, Type 2
|Active
|08/10/2008
|----
|}

{| 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
|----
|206833
|Medication
|metaproternol sulfate
|Alupent Inhalation Aerosol
|15 mg/ml
|2 Puffs
|Inhaled
|Q4h
|12/22/2009
|Active
|----
|205875
|Medication
|glyburide
|Diabeta
|2.5 mg
|1 Tablet
|PO
|Q AM
|08/10/2008
|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
|91936005
|Penicillin
|Rash and anaphylaxis
|08/10/2008
|----
|Drug Allergy
|293620004
|Indomethacin
|Nausea, vomiting, rash, dizziness, headache
|03/25/2003
|----
|}

{| 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
|24648-8
|Chest X-ray, PA
|Increased bronchial wall markings, patchy infiltrates
|02/16/2010
|----
|Chemistry
|14771-0
|Fasting Blood Glucose (70–100 mg/dl)
|70 mg/dl
|12/22/2009
|----
|Hematology
|26449-9
|Eosinophil Count (1 – 3 %)
|2%
|12/22/2009
|----
|Imaging
|24648-8
|Chest X-ray, PA
|Bronchial wall markings
|12/22/2009
|----
|}

[https://trac.opensourcevista.net/browser/hData/trunk/test-patients/NIST-Ambulatory-test-patient-1.csv CSV Format]