| Patient | Kim Chrisman | ||
| Date of birth | August 5, 1940, 04:00:00 | Sex | Female |
| Race | Asian | Ethnicity | Not Hispanic or Latino |
| Contact info | Pirmary Home: 202 Burlington Rd. Bedford, MA 01730 Tel: +1-781-271-3000 |
Patient IDs | 4fe1ecd2a9ffcc03cd000ad5 Cypress |
| Document Id | HITSP_C32v2.5_Rev6_16Sections_Entries_MinimalErrors 2.16.840.1.113883.3.72 |
| Document Created: | June 20, 2012, 15:31:31 |
| Author | Auto Generated |
| Contact info |
Tel: +1-781-271-3000 |
| Document maintained by | Cypress |
| Contact info | 202 Burlington Rd. Bedford, MA 01730 Tel: +1-781-271-3000 |
| Description | Code | Time |
|---|---|---|
| No Known allergies | 160244002 | 20120620153131 |
| Description | Codes | Time |
|---|---|---|
| Antihypertensive combinations | RxNorm: 858828 C0976596:Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet; |
March 31st, 2010 04:00 |
| ACE inhibitor or ARB | RxNorm: 314076 C0981555:Lisinopril 10 MG Oral Tablet; |
June 10th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Encounter Outpatient | CPT: 99213 ICD-9-CM: V70.0 C0374559:Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.; |
October 27th, 2010 04:00 |
| Encounter Office Visit | CPT: 99212 C0374558:Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.; |
June 25th, 2010 04:00 |
| encounter acute inpt | CPT: 99251 C0374574:Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 20 minutes at the bedside and on the patient's hospital floor or unit.; |
June 8th, 2010 04:00 |
| Encounter Outpatient | CPT: 99213 ICD-9-CM: V70.0 C0374559:Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.; |
June 6th, 2010 04:00 |
| Encounter Office Visit | CPT: 99212 C0374558:Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.; |
March 31st, 2010 04:00 |
| Description | Codes | Time | Status |
|---|---|---|---|
| Colon Cancer | SNOMED-CT: 126838000 ICD-9-CM: 153.9 ICD-10-CM: C18.9 C0007102:Malignant tumor of colon; C0346629:Malignant neoplasm of large intestine; |
June 6th, 2010 04:00 | active |
| Acute Renal Insufficiency | ICD-9-CM: 593.9 ICD-10-CM: N28.9 SNOMED-CT: 14669001 C0022660:Kidney Failure, Acute; |
June 8th, 2010 04:00 | active |
| Hypertension | ICD-9-CM: 401.9 ICD-10-CM: I10 SNOMED-CT: 59621000 C2882073:hypertension (arterial) (benign) (essential) (malignant) (primary) (systemic); C0020538:Hypertensive disease; C0085580:Essential Hypertension; |
March 31st, 2010 04:00 | active |
| low back pain | ICD-9-CM: 724.2 ICD-10-CM: M54.9 SNOMED-CT: 279039007 C0024031:Low Back Pain; |
March 31st, 2010 04:00 | active |
| Description | Codes | Time | Value |
|---|---|---|---|
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
October 27th, 2010 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
October 27th, 2010 04:00 | |
| Heart Rate | SNOMED-CT: 364075005 C0018810:heart rate; |
October 27th, 2010 04:00 | |
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
March 31st, 2010 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
March 31st, 2010 04:00 | |
| Heart Rate | SNOMED-CT: 364075005 C0018810:heart rate; |
March 31st, 2010 04:00 | |
| BMI | SNOMED-CT: 60621009 LOINC: 39156-5 C1542867:Body mass index:Relative Density:Point in time:^Patient:Quantitative; |
June 6th, 2010 04:00 | |
| colonoscopy | CPT: 45378 HCPCS: G0121 ICD-9-CM: 45.23 SNOMED-CT: 456004 ICD-10-CM: Z12.11 C0878742:Encounter for screening for malignant neoplasms of colon; |
June 6th, 2010 04:00 | |
| Colon Cancer Stage III | SNOMED-CT: 369921003 C1276570:T3: Colon/rectum tumor invades through the muscularis propria into the subserosa or the nonperitonealized pericolic or perirectal soft tissues; |
June 12th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| counseling for nutrition | CPT: 97802 ICD-9-CM: V65.3 HCPCS: S9470 ICD-10-CM: Z00.8 C2910467:Encounter for other general examination; C2910466:Encounter for health examination in population surveys; |
June 6th, 2010 04:00 |
| counseling for physical activity | ICD-9-CM: V65.41 HCPCS: S9451 ICD-10-CM: Z71.3 C0260823:Encounter for dietary surveillance and counseling; |
June 6th, 2010 04:00 |
| colonoscopy | CPT: 45378 HCPCS: G0121 ICD-9-CM: 45.23 SNOMED-CT: 456004 ICD-10-CM: Z12.11 C0878742:Encounter for screening for malignant neoplasms of colon; |
June 6th, 2010 04:00 |
| Colon Cancer Stage III | SNOMED-CT: 369921003 C1276570:T3: Colon/rectum tumor invades through the muscularis propria into the subserosa or the nonperitonealized pericolic or perirectal soft tissues; |
June 12th, 2010 04:00 |
| Colorectal Cancer | SNOMED-CT: 363406005 ICD-10-CM: C18 ICD-9-CM: 153.9 HCPCS: G0213 Pet imaging whole body; diagnosis; colorectal |
June 6th, 2010 04:00 |
| Imaging Study-Spinal | CPT: 72010 SNOMED-CT: 91583001 C0203144:Diagnostic radiography of spine, survey study; |
March 31st, 2010 04:00 |
| Description | Codes | Time | Value |
|---|---|---|---|
| Total Cholesterol | CPT: 82465 LOINC: 2093-3 SNOMED-CT: 121868005 C0546633:Cholesterol total measurement; |
March 31st, 2010 04:00 | |
| Triglycerides | CPT: 84478 LOINC: 12951-0 SNOMED-CT: 14740000 C0202236:Triglycerides measurement; |
March 31st, 2010 04:00 | |
| High Density Lipoprotein (HDL) | CPT: 83701 LOINC: 14646-4 SNOMED-CT: 28036006 C0392885:High density lipoprotein measurement; |
March 31st, 2010 04:00 | |
| LDL Laboratory Test | LOINC: 2089-1 C0364225:Cholesterol.in LDL:Mass Concentration:Point in time:Serum/Plasma:Quantitative; |
March 31st, 2010 04:00 | |
| colonoscopy | CPT: 45378 HCPCS: G0121 ICD-9-CM: 45.23 SNOMED-CT: 456004 ICD-10-CM: Z12.11 C0878742:Encounter for screening for malignant neoplasms of colon; |
June 6th, 2010 04:00 | |
| Colon Cancer Stage III | SNOMED-CT: 369921003 C1276570:T3: Colon/rectum tumor invades through the muscularis propria into the subserosa or the nonperitonealized pericolic or perirectal soft tissues; |
June 12th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Influenza Vaccine | RxNorm: 857942 C2718407:Influenza Virus Vaccine, Inactivated A-Brisbane-59-2007, IVR-148 (H1N1) strain 0.03 MG/ML / Influenza Virus Vaccine, Inactivated A-Uruguay-716-2007, NYMC X-175C (H3N2) strain 0.03 MG/ML / Influenza Virus Vaccine, Inactivated B-Brisbane-60-2008 strain 0.03 MG/ML Injectable Suspension; |
October 27th, 2010 04:00 |
| Pneumococcal Vaccine all ages | CVX: 100 CPT: 90669 C2724348:Pneumococcal conjugate vaccine, 7 valent, for intramuscular use; |
October 27th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| follow-up plan_BMI management | CPT: 97804 HCPCS: S9470 SNOMED-CT: 305849009 ICD-9-CM: V65.3 C0260823:Encounter for dietary surveillance and counseling; |
June 6th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Tobacco Non-User | SNOMED-CT: 160618006 C0425311:Current non-smoker; |
March 31st, 2010 04:00 |