NIST-EP-Patient-1-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 #1|Office Visit #2 for Jonas Barnaby

Patient
Name	Date/Time of Birth	Gender	Identification Number	Identification Number Type	Address/Phone
Jonas Barnaby	07/14/1961 12:30:24	Male	969988999	Medical Record Number	478 Charles Street, Williamsport, Pennsylvania 17701 570-857-8593

“Source” for all data for this patient: Marcus Welby, MD

Problem List
Type	ICD-9 Code	Patient Problem	Status	Date Diagnosed
Condition	272.4	Hyperlipidemia	Active	02/20/2010

Problem List
Type	SNOMED Code*	Patient Problem	Status	Date Diagnosed
Disorder	55822004	Hyperlipidemia	Active	02/20/2010

Medication List
RxNorm Code	Product	Generic Name	Brand Name	Strength	Dose	Route	Frequency	Date Started	Status
617314	Medication	atorvastatin calcium	Lipitor	10 mg	1 Tablet	PO	Q Day	02/20/2010	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	14647-2	Total cholesterol (<200 mg/dl)	262 mg/dl	02/20/2010
Chemistry	14646-4	HDL cholesterol (?40 mg/dl)	78 mg/dl	02/20/2010
Chemistry	2089-1	LDL cholesterol (<100 mg/dl)	184 mg/dl	02/20/2010
Chemistry	14927-8	Triglycerides (<150 mg/dl)	177 mg/dl	02/20/2010

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