NIST-Inpatient-test-patient-1

TD170.306.f.: Exchange clinical information and patient summary record

• 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
Ann Toliver	07/16/1950 14:15:12	Female	989285998	Medical Record Number	353 Wine Street Flint, Michigan 48503 810-673-8378

“Source” for all data for this patient: Fatima Goyal, MD

Problem List
Type	ICD-9 Code	Patient Problem	Status	Date Diagnosed
Diagnosis	428.0	Congestive Heart Failure	Active	02/22/2010
Diagnosis	410.90	Acute Myocardial Infarction	Resolved	09/16/2007
Type	SNOMED Code*	Patient Problem	Status	Date Diagnosed
Disorder	42343007	Congestive Heart Failure	Active	02/22/2010
Disorder	57054005	Acute Myocardial Infarction	Resolved	09/16/2007

Medication List
RxNorm Code	Product	Generic Name	Brand Name	Strength	Dose	Route	Frequency	Date Started	Status
201372	Medication	captopril	Capoten	25 mg	Tablet	PO	TID	02/25/2010	Active
200820	Medication	spironolactone	Aldactone	25 mg	Tablet	PO	QID	02/25/2010	Active
309888	Medication	digoxin	Lanoxin	125 mcg	Tablet	PO	QD	02/25/2010	Active
628958	Medication	potassium chloride	Klor-Con	10 mEq	1 Tablet	PO	BID	02/25/2010	Active
198039	Medication	nitroglycerin	Nitroglycerin	400 mcg	1 Tablet	SL	As needed	09/20/2007	Active

Medication Allergy List
Type	SNOMED Code	Medication/Agent	Reaction	Date Recorded
Drug Allergy	293586001	Aspirin	Wheezing	03/02/2007
Drug Allergy	294506009	Ampicillin	Diarrhea, nausea, vomiting	04/25/1994

Diagnostic Test Results
Type	LOINC Code	Test (Normal Range)	Result	Date Performed
Imaging	24648-8	Chest X-ray, PA	Enlarged cardiac silhouette, lung fields clear	02/24/2010
Chemistry	2951-2	Sodium (135–146 mg/dl)	138 mg/dl	02/24/2010
Chemistry	2823-3	Potassium (3.5–5.3 mg/dl)	4.3 mg/dl	02/24/2010
Chemistry	2075-0	Chloride (95-107 mEq/L)	98 mEq/L	02/24/2010
Imaging	24648-8	Chest X-ray, PA	Enlarged cardiac silhouette, horizontal lines in the periphery of lower posterior lung fields	02/22/2010
Chemistry	2951-2	Sodium (135–146 mg/dl)	126 mg/dl	02/22/2010
Chemistry	2823-3	Potassium (3.5–5.3 mg/dl)	3.0 mg/dl	02/22/2010
Chemistry	2075-0	Chloride (95-107 mEq/L)	94 mEq/L	02/22/2010

Procedure List
Type	ICD-9 Code	Procedure	Status	Date Performed
Cardiac	00.66	Percutaneous transluminal coronary angioplasty	Completed	09/17/2007
Cardiac	37.21	Cardiac catheterization	Completed	10/01/2006
Type	CPT Code*	Procedure	Status	Date Performed
Cardiac	92982	Percutaneous transluminal coronary angioplasty	Completed	09/17/2007
Cardiac	93501	Cardiac catheterization	Completed	10/01/2006

--Glilly 13:55, 22 Nov 2010 (PST)