NIST-EP-Patient-4-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 #4|Office Visit #2 for Susan Ellerby

Patient
Name	Date/Time of Birth	Gender	Identification Number	Identification Number Type	Address/Phone
Susan Ellerby	12/08/1963 21:54:24	Female	925377799	Medical Record Number	483 Powell Street, Shawville, Pennsylvania 16873 814-645-9475

“Source” for all data for this patient: Dorcas Wayne, MD

Problem List
Type	ICD-9 Code	Patient Problem	Status	Date Diagnosed
Symptom	401.9	Hypertension, Essential	Active	02/05/2010
Type	SNOMED Code*	Patient Problem	Status	Date Diagnosed
Disorder	59621000	Essential Hypertension	Active	02/05/2010

Medication List
RxNorm Code	Product	Generic Name	Brand Name	Strength	Dose	Route	Frequency	Date Started	Status
200801	Medication	furosemide	Lasix	20 mg	1 Tablet	PO	BID	02/05/2010	Active
628958	Medication	potassium chloride	Klor-Con	10 mEq	1 Tablet	PO	BID	02/05/2010	Active

Medication Allergy List
Type	SNOMED Code	Medication/Agent	Reaction	Date Recorded
Drug Allergy	91936005	Penicillin	Rash and anaphylaxis	05/22/1998
Drug Allergy	293597001	Codeine	Hives	02/17/1992

Diagnostic Test Results
Type	LOINC Code	Test (Normal Range)	Result	Date Performed
Chemistry	2823-3	Potassium (3.5–5.3 mg/dl)	4.5 mg/dl	02/05/2010
Imaging	42272-5	Chest X-ray, PA & Lateral	The heart outline is normal and the hilar and mediastinal vessels are of normal appearance	02/05/2010

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