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#REDIRECT [[NIST Inpatient Test Patients:set 5]]
Patient Summary Record Test Data – Set #3


{| 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
|----
|Lorraine Blevins
|04/16/1957<br>20:15:35
|Female
|967385998
|Medical Record Number
|1020 Stuart Street<br>Morton, <br>Illinois  61550<br> 309-374-8938
|----
|}
“Source” for all data for this patient: Louis Randolph, 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
|715.35
|Right hip osteoarthritis
|Resolved
|02/12/2010
|----
|Finding
|414.01
|Coronary Artery Disease (CAD)
|Chronic
|05/05/2002
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|239872002
|Right hip osteoarthritis
|Resolved
|02/12/2010
|----
|Disorder
|53741008
|Coronary Arteriosclerosis
|Chronic
|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
|----
|855320
|Medication
|warfarin
|Coumadin
|3 mg
|1 Tablet
|PO
|QD
|02/15/2010
|Active
|----
|209613
|Medication
|bisacodyl
|Dulcolax
|5 mg
|1 Tablet
|PO
|QD
|02/15/2010
|Active
|----
|309362
|Medication
|clopidogrel
|Plavix
|75 mg
|1 Tablet
|PO
|QD
|05/15/2002
|Active
|----
|197361
|Medication
|amlodipine
|Norvasc
|5 mg
|1 Tablet
|PO
|QD
|07/15/2009
|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
|91939003
|Sulfonamides
|Hives, photosensitivity
|06/06/1998
|----
|Drug Allergy
|294506009
|Ampicillin
|Diarrhea, nausea, vomiting
|04/25/1994
|----
|}
{| 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
|----
|Imaging
|37721-8
|X-ray, 2 views, Right Hip
|Subchondral sclerosis,<br> increased density in<br>subchondral bone
|02/12/2010
|----
|Imaging
|24648-8
|Chest X-ray, PA
|No disease is seen in<br> the lung fields or pleura
|06/05/2009
|----
|Hematology
|718-7
|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)
|11.2 g/dl
|06/05/2009
|----
|Hematology
|4544-3
|Hematocrit (male: 40-54% <br>female: 36-48%)
|34%
|06/05/2009
|----
|Coagulation
|34714-6
|Prothrombin Time/ International Normalized Ratio (PT/INR)<br>(2.5 – 3.5)
|3.1
|06/05/2009
|----
|}
{| border="1"|
!colspan="5"|Procedure List
|----
!scope="col"|Type
!scope="col"|ICD-9 Code
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Surgical
|81.51
|Total Hip Replacement, Right
|Completed
|02/14/2010
|----
|Cardiac
|37.21
|Cardiac catheterization
|Completed
|05/05/2002
|----
|----
!scope="col"|Type
!scope="col"|CPT Code*
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Surgical
|27130
|Total Hip Replacement, Right
|Completed
|02/14/2010
|----
|Cardiac
|93501
|Cardiac catheterization
|Completed
|05/05/2002
|----
--[[User:Glilly|Glilly]] 11:35, 22 Nov 2010 (PST)

Revision as of 19:35, 22 November 2010

Patient Summary Record Test Data – Set #3

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Lorraine Blevins 04/16/1957
20:15:35 		Female 967385998 Medical Record Number 1020 Stuart Street
Morton,
Illinois 61550
309-374-8938

“Source” for all data for this patient: Louis Randolph, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 715.35 Right hip osteoarthritis Resolved 02/12/2010
Finding 414.01 Coronary Artery Disease (CAD) Chronic 05/05/2002
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 239872002 Right hip osteoarthritis Resolved 02/12/2010
Disorder 53741008 Coronary Arteriosclerosis Chronic 05/05/2002
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
855320 Medication warfarin Coumadin 3 mg 1 Tablet PO QD 02/15/2010 Active
209613 Medication bisacodyl Dulcolax 5 mg 1 Tablet PO QD 02/15/2010 Active
309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 05/15/2002 Active
197361 Medication amlodipine Norvasc 5 mg 1 Tablet PO QD 07/15/2009 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 06/06/1998
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 04/25/1994
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Imaging 37721-8 X-ray, 2 views, Right Hip Subchondral sclerosis,
increased density in
subchondral bone 		02/12/2010
Imaging 24648-8 Chest X-ray, PA No disease is seen in
the lung fields or pleura 		06/05/2009
Hematology 718-7 Hemoglobin (male: 14-18 g/dl
female: 12-16 g/dl) 		11.2 g/dl 06/05/2009
Hematology 4544-3 Hematocrit (male: 40-54%
female: 36-48%) 		34% 06/05/2009
Coagulation 34714-6 Prothrombin Time/ International Normalized Ratio (PT/INR)
(2.5 – 3.5) 		3.1 06/05/2009
--Glilly 11:35, 22 Nov 2010 (PST)
Procedure List
Type ICD-9 Code Procedure Status Date Performed
Surgical 81.51 Total Hip Replacement, Right Completed 02/14/2010
Cardiac 37.21 Cardiac catheterization Completed 05/05/2002
Type CPT Code* Procedure Status Date Performed
Surgical 27130 Total Hip Replacement, Right Completed 02/14/2010
Cardiac 93501 Cardiac catheterization Completed 05/05/2002
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