NIST-EP-Patient-3-Visit-2

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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 #3|Office Visit #2 for Barbara Simpson

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Barbara Simpson 10/12/1956 19:47:01 Female 9688675266 Medical Record Number 996 Dalton Street,
Fargo,
North Dakota 54102
701-366-5534

“Source” for all data for this patient: Robert James, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 496.0 Chronic Obstructive Pulmonary Disease Chronic 02/10/2010
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 13645005 Chronic Obstructive Lung Disease Chronic 02/10/2010
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
836370 Medication ipratropium bromide monohydrate Atrovent Inhaler 18 mcg/puff 2 Puffs Inhaled QID 02/10/2010 Active
630208 Medication albuterol sulfate Albuterol Inhaler 2.5 mg/3ml 2 Puffs Inhaled Q 4 hours as needed 02/10/2010 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 91936005 Penicillin Rash and anaphylaxis 06/10/2009
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 04/25/1988
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Imaging 42272-5 Chest X-ray, PA & Lateral Hyperinflated lungs with flattened diaphragm and central pulmonary artery enlargement 02/10/2010
Hematology 718-7 Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) 16 g/dl 02/10/2010
Hematology 4544-3 Hematocrit (male: 40-54% female: 36-48%) 45% 02/10/2010

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