NIST-EP-Patient-2-Visit-1: Difference between revisions
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DaveMishler (talk | contribs) Initial data entry |
m Added glossary link to Allergy~ |
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{| border="1"| | {| border="1"| | ||
!colspan="5"|Medication Allergy List | !colspan="5"|Medication [[Allergy~|Allergy]] List | ||
|---- | |---- | ||
!scope="col"|Type | !scope="col"|Type | ||
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!scope="col"|Date Recorded | !scope="col"|Date Recorded | ||
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|Drug Allergy | |Drug [[Allergy~|Allergy]] | ||
|91936005 | |91936005 | ||
|Penicillin | |Penicillin | ||
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|08/10/2008 | |08/10/2008 | ||
|---- | |---- | ||
|Drug Allergy | |Drug [[Allergy~|Allergy]] | ||
|293620004 | |293620004 | ||
|Indomethacin | |Indomethacin | ||
Revision as of 08:20, 22 February 2012
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 #2|Office Visit #1 for Robert Flint
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Robert Flint | 04/18/1983 20:18:04 | Male | 9813624798 | Medical Record Number | 747 Market Street, Morton, Illinois 61550 309-365-8298 |
“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 | 07/19/2009 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 195967001 | Asthma | Active | 07/19/2009 | |
| Medication List | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
| 206833 | Medication | metaproterenol sulfate | Alupent Inhalation Aerosol | 15 mg/ml | 2 Puffs | Inhaled | Q4h | 07/19/2009 | 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 | 07/19/2009 |
