NIST Ambulatory Test Patient 1: Difference between revisions

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* indicates alternative standard code per certification criteria
 
Patient Summary Record Test Data – Set #1
 
{| 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
|----
|John D. Smith
|07/04/1960 10:15:02
|Male
|999999999
|Medical Record Number
|355 Maple Street <br>Williamsport, <br>Pennsylvania 17701 <br>570-837-8364
|----
|}
 
“Source” for all data for this patient: John Fitzgerald, 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
|250.02
|Diabetes Mellitus, Type 2
|Active
|09/16/2009
|----
|Condition
|272.4
|Hyperlipidemia
|Active
|05/05/2002
|----
|Finding
|414.01
|Coronary Artery Disease (CAD)
|Chronic
|05/05/2002
|----
|Symptom
|401.9
|Hypertension, Essential
|Active
|05/05/2002
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|44054006
|Diabetes Mellitus, Type 2
|Active
|09/16/2009
|----
|Disorder
|55822004
|Hyperlipidemia
|Active
|05/05/2002
|----
|Disorder
|53741008
|Coronary Arteriosclerosis
|Chronic
|05/05/2002
|----
|Disorder
|59621000
|Essential Hypertension
|Active
|05/05/2002
|----
|}
 
{| 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
|----
|205875
|Medication
|glyburide
|Diabeta
|2.5 mg
|1 Tablet
|PO
|Q AM
|09/16/2009
|Active
|----
|617314
|Medication
|atorvastatin calcium
|Lipitor
|10 mg
|1 Tablet
|PO
|Q Day
|05/05/2002
|Active
|----
|200801
|Medication
|furosemide
|Lasix
|20 mg
|1 Tablet
|PO
|BID
|05/05/2002
|Active
|----
|628958
|Medication
|potassium chloride
|Klor-Con
|10 mEq
|1 Tablet
|PO
|BID
|05/05/2002
|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
|293597001
|Codeine
|Hives
|06/27/1996
|----
|Drug Allergy
|294506009
|Ampicillin
|Diarrhea, nausea, vomiting
|03/15/1994
|----
|}
 
{| 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
|----
|Chemistry
|14771-0
|Fasting Blood Glucose (70–100 mg/dl)
|178 mg/dl
|09/16/2009
|----
|Chemistry
|14682-9
|Creatinine (0.5–1.4 mg/dl)
|1.0 mg/dl
|09/16/2009
|----
|Chemistry
|14937-7
|BUN (7–30 mg/dl)
|18 mg/dl
|09/16/2009
|----
|Chemistry
|2951-2
|Sodium (135–146 mg/dl)
|141 mg/dl
|09/16/2009
|----
|Chemistry
|2823-3
|Potassium (3.5–5.3 mg/dl)
|4.3 mg/dl
|09/16/2009
|----
|Chemistry
|14647-2
|Total cholesterol (<200 mg/dl)
|162 mg/dl
|09/16/2009
|----
|Chemistry
|14646-4
|HDL cholesterol (?40 mg/dl)
|43 mg/dl
|09/16/2009
|----
|Chemistry
|2089-1
|LDL cholesterol (<100 mg/dl)
|84 mg/dl
|09/16/2009
|----
|Chemistry
|14927-8
|Triglycerides (<150 mg/dl)
|177 mg/dl
|09/16/2009
|----
|Imaging
|24648-8
|Chest X-ray, PA
|No disease is seen in the<br>lung fields or pleura
|09/16/2009
|----
|}
--[[User:Glilly|Glilly]] 23:27, 21 Nov 2010 (PST)

Revision as of 07:27, 22 November 2010

* indicates alternative standard code per certification criteria

Patient Summary Record Test Data – Set #1

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
John D. Smith 07/04/1960 10:15:02 Male 999999999 Medical Record Number 355 Maple Street
Williamsport,
Pennsylvania 17701
570-837-8364

“Source” for all data for this patient: John Fitzgerald, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 09/16/2009
Condition 272.4 Hyperlipidemia Active 05/05/2002
Finding 414.01 Coronary Artery Disease (CAD) Chronic 05/05/2002
Symptom 401.9 Hypertension, Essential Active 05/05/2002
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 44054006 Diabetes Mellitus, Type 2 Active 09/16/2009
Disorder 55822004 Hyperlipidemia Active 05/05/2002
Disorder 53741008 Coronary Arteriosclerosis Chronic 05/05/2002
Disorder 59621000 Essential Hypertension Active 05/05/2002
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 09/16/2009 Active
617314 Medication atorvastatin calcium Lipitor 10 mg 1 Tablet PO Q Day 05/05/2002 Active
200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 05/05/2002 Active
628958 Medication potassium chloride Klor-Con 10 mEq 1 Tablet PO BID 05/05/2002 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 293597001 Codeine Hives 06/27/1996
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/15/1994
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Chemistry 14771-0 Fasting Blood Glucose (70–100 mg/dl) 178 mg/dl 09/16/2009
Chemistry 14682-9 Creatinine (0.5–1.4 mg/dl) 1.0 mg/dl 09/16/2009
Chemistry 14937-7 BUN (7–30 mg/dl) 18 mg/dl 09/16/2009
Chemistry 2951-2 Sodium (135–146 mg/dl) 141 mg/dl 09/16/2009
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.3 mg/dl 09/16/2009
Chemistry 14647-2 Total cholesterol (<200 mg/dl) 162 mg/dl 09/16/2009
Chemistry 14646-4 HDL cholesterol (?40 mg/dl) 43 mg/dl 09/16/2009
Chemistry 2089-1 LDL cholesterol (<100 mg/dl) 84 mg/dl 09/16/2009
Chemistry 14927-8 Triglycerides (<150 mg/dl) 177 mg/dl 09/16/2009
Imaging 24648-8 Chest X-ray, PA No disease is seen in the
lung fields or pleura 		09/16/2009

--Glilly 23:27, 21 Nov 2010 (PST)

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