NIST-EP-Patient-3-Visit-1: Difference between revisions
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m Added glossary link to Allergy~ |
Added glossary link to Record~ |
||
| Line 22: | Line 22: | ||
|Female | |Female | ||
|9688675266 | |9688675266 | ||
|Medical Record Number | |Medical [[Record~|Record]] Number | ||
|996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534 | |996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534 | ||
|---- | |---- | ||
| Line 93: | Line 93: | ||
!scope="col"|Medication/Agent | !scope="col"|Medication/Agent | ||
!scope="col"|Reaction | !scope="col"|Reaction | ||
!scope="col"|Date | !scope="col"|Date [[Record~|Record]]ed | ||
|---- | |---- | ||
|Drug [[Allergy~|Allergy]] | |Drug [[Allergy~|Allergy]] | ||
Latest revision as of 12:57, 7 April 2012
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 |
