NIST-EP-Patient-5-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 #5|Office Visit #2 for Johnathan Stone

Patient
Name	Date/Time of Birth	Gender	Identification Number	Identification Number Type	Address/Phone
Johnathan Stone	11/12/1966 08:18:08	Male	988772587	Medical Record Number	937 Sutter Street Aurora, Colorado 80011 303-544-9988

“Source” for all data for this patient: Samuel Johnston, MD

Problem List
Type	ICD-9 Code	Patient Problem	Status	Date Diagnosed
Symptom	401.9	Hypertension, Essential	Active	01/15/2010
Type	SNOMED Code*	Patient Problem	Status	Date Diagnosed
Disorder	59621000	Essential Hypertension	Active	01/15/2010

Medication List
RxNorm Code	Product	Generic Name	Brand Name	Strength	Dose	Route	Frequency	Date Started	Status
200801	Medication	furosemide	Lasix	20 mg	1 Tablet	PO	BID	01/15/2010	Active
628958	Medication	potassium chloride	Klor-Con	10 mEq	1 Tablet	PO	BID	01/15/2010	Active

Medication Allergy List
Type	SNOMED Code	Medication/Agent	Reaction	Date Recorded
Drug Allergy	294506009	Ampicillin	Diarrhea, nausea, vomiting	03/25/1997
Drug Allergy	91939003	Sulfonamides	Hives, photosensitivity	04/25/1989

Diagnostic Test Results
Type	LOINC Code	Test (Normal Range)	Result	Date Performed
Chemistry	2823-3	Potassium (3.5–5.3 mg/dl)	4.5 mg/dl	01/15/2010
Imaging	42272-5	Chest X-ray, PA & Lateral	The heart outline is normal and the hilar and mediastinal vessels are of normal appearance	01/15/2010

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