NIST Ambulatory Test Patient 2

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Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary Record  APPROVED (Pending) Version 1.0  July 21, 2010  

Patient Summary Record Test Data – Set #2

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Ralph Johnson 06/28/1984 13:20:10 Male 9813466798 Medical Record Number 355 Elm Street
Morton,
Illinois 61550
309-377-8365

“Source” for all data for this patient: Carl Roberts, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 493.00 Asthma, unspecified Active 12/22/2009
Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 08/10/2008
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 195967001 Asthma Active 12/22/2009
Disorder 44054006 Diabetes Mellitus, Type 2 Active 08/10/2008
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
206833 Medication metaproternol sulfate Alupent Inhalation Aerosol 15 mg/ml 2 Puffs Inhaled Q4h 12/22/2009 Active
205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 08/10/2008 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
Imaging 24648-8 Chest X-ray, PA Increased bronchial wall
markings, patchy infiltrates
02/16/2010
Chemistry 14771-0 Fasting Blood Glucose (70–100 mg/dl) 70 mg/dl 12/22/2009
Hematology 26449-9 Eosinophil Count (1 – 3 %) 2% 12/22/2009
Imaging 24648-8 Chest X-ray, PA Bronchial wall markings 12/22/2009

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