Difference between revisions of "NIST-EP-Patient-2-Visit-2"
From VistApedia
m (Added glossary link to Allergy~) |
(Added glossary link to Record~) |
||
| Line 22: | Line 22: | ||
|Male | |Male | ||
|9813624798 | |9813624798 | ||
| − | |Medical Record Number | + | |Medical [[Record~|Record]] Number |
|747 Market Street,<br>Morton,<br>Illinois 61550<br>309-365-8298 | |747 Market Street,<br>Morton,<br>Illinois 61550<br>309-365-8298 | ||
|---- | |---- | ||
| 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 12:41, 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 #2|Office Visit #2 for Robert Flint
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Robert Flint | 04/18/1983 20:18:04 | Male | 9813624798 | Medical Record Number | 747 Market Street, Morton, Illinois 61550 309-365-8298 |
“Source” for all data for this patient: Carl Roberts, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Diagnosis | 250.02 | Diabetes Mellitus, Type 2 | Active | 03/10/2010 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 44054006 | Diabetes Mellitus, Type 2 | Active | 03/10/2010 | |
| 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 | 03/10/2010 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 91936005 | Penicillin | Rash and anaphylaxis | 08/10/2008 |
| Drug Allergy | 293620004 | Indomethacin | Nausea, vomiting, rash, dizziness, headache | 03/25/2003 |
| Diagnostic Test Results | ||||
|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
| Chemistry | 14771-0 | Fasting Blood Glucose (70–100 mg/dl) | 150 mg/dl | 03/10/2010 |
| Imaging | 24648-8 | Chest X-ray, PA | The heart outline is normal and the hilar and mediastinal vessels are of normal appearance | 03/10/2010 |
