NIST-EP-Patient-4-Visit-1

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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 #1 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
Condition 272.4 Hyperlipidemia Active 07/06/2010
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 55822004 Hyperlipidemia Active 07/06/2010
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 07/06/2010 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 14647-2 Total cholesterol (<200 mg/dl) 279 mg/dl 07/06/2010
Chemistry 14646-4 HDL cholesterol (?40 mg/dl) 89 mg/dl 07/06/2010
Chemistry 2089-1 LDL cholesterol (<100 mg/dl) 190 mg/dl 07/06/2010
Chemistry 14927-8 Triglycerides (<150 mg/dl) 187 mg/dl 07/06/2010

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