| Patient | Lance Dumlao | ||
| Date of birth | June 7, 1940, 04:00:00 | Sex | Male |
| Race | American Indian Or Alaska Native | Ethnicity | Not Hispanic or Latino |
| Contact info | Pirmary Home: 202 Burlington Rd. Bedford, MA 01730 Tel: +1-781-271-3000 |
Patient IDs | 4fe1ed01a9ffcc03cd001764 Cypress |
| Document Id | HITSP_C32v2.5_Rev6_16Sections_Entries_MinimalErrors 2.16.840.1.113883.3.72 |
| Document Created: | June 20, 2012, 15:32:17 |
| 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 | 20120620153217 |
| Description | Codes | Time |
|---|---|---|
| Oral anti-platelet therapy | RxNorm: 243670 C0783425:Aspirin 81 MG Oral Tablet; |
April 9th, 2010 04:00 |
| Oral anti-platelet therapy | RxNorm: 243670 C0783425:Aspirin 81 MG Oral Tablet; |
August 29th, 2009 04:00 |
| Antihypertensive combinations | RxNorm: 858828 C0976596:Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet; |
April 9th, 2010 04:00 |
| Antihypertensive combinations | RxNorm: 858828 C0976596:Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet; |
August 29th, 2009 04:00 |
| Description | Codes | Time |
|---|---|---|
| Encounter Ophthalmological Services | CPT: 92012 C0374194:Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient; |
October 4th, 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.; |
September 25th, 2010 04:00 |
| Encounter Ophthalmological Services | CPT: 92012 C0374194:Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient; |
May 23rd, 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.; |
April 9th, 2010 04:00 |
| Encounter Inpatient Discharge | CPT: 99238 C0374572:Hospital discharge day management; 30 minutes or less; |
August 29th, 2009 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.; |
August 26th, 2009 04:00 |
| Description | Codes | Time | Status |
|---|---|---|---|
| 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; |
April 9th, 2010 04:00 | active |
| ischemic vascular disease | ICD-9-CM: 411.89 ICD-10-CM: I24 SNOMED-CT: 52674009 C0022116:Ischemia; |
August 26th, 2009 04:00 | active |
| Primary Open Angle Glaucoma (POAG) | ICD-9-CM: 365.10 ICD-10-CM: H40.13 SNOMED-CT: 84494001 C0017612:Glaucoma, Open-Angle; |
May 23rd, 2010 04:00 | active |
| Description | Codes | Time | Value |
|---|---|---|---|
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
September 25th, 2010 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
September 25th, 2010 04:00 | |
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
April 9th, 2010 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
April 9th, 2010 04:00 | |
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
August 26th, 2009 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
August 26th, 2009 04:00 | |
| BMI | SNOMED-CT: 60621009 LOINC: 39156-5 C1542867:Body mass index:Relative Density:Point in time:^Patient:Quantitative; |
September 25th, 2010 04:00 | |
| BMI | SNOMED-CT: 60621009 LOINC: 39156-5 C1542867:Body mass index:Relative Density:Point in time:^Patient:Quantitative; |
April 9th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Optic Nerve Head Evaluation | SNOMED-CT: 36228007 C0200149:Ophthalmic examination and evaluation; |
May 23rd, 2010 04:00 |
| Description | Codes | Time | Value |
|---|---|---|---|
| LDL | CPT: 83721 LOINC: 2089-1 SNOMED-CT: 113079009 C0202117:Low density lipoprotein cholesterol measurement; |
September 25th, 2010 04:00 | |
| High Density Lipoprotein (HDL) | CPT: 83701 LOINC: 14646-4 SNOMED-CT: 28036006 C0392885:High density lipoprotein measurement; |
September 25th, 2010 04:00 | |
| Total Cholesterol | CPT: 82465 LOINC: 2093-3 SNOMED-CT: 121868005 C0546633:Cholesterol total measurement; |
September 25th, 2010 04:00 | |
| Triglycerides | CPT: 84478 LOINC: 12951-0 SNOMED-CT: 14740000 C0202236:Triglycerides measurement; |
September 25th, 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; |
September 25th, 2010 04:00 |
| Pneumococcal Vaccine all ages | CVX: 100 CPT: 90669 C2724348:Pneumococcal conjugate vaccine, 7 valent, for intramuscular use; |
September 25th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Tobacco Non-User | SNOMED-CT: 160618006 C0425311:Current non-smoker; |
April 9th, 2010 04:00 |