| Patient | Hugh Staker | ||
| Date of birth | April 19, 1959, 05:00:00 | Sex | Male |
| Race | Other Race | Ethnicity | Hispanic or Latino |
| Contact info | Pirmary Home: 202 Burlington Rd. Bedford, MA 01730 Tel: +1-781-271-3000 |
Patient IDs | 4fe1ecfba9ffcc03cd0015c7 Cypress |
| Document Id | HITSP_C32v2.5_Rev6_16Sections_Entries_MinimalErrors 2.16.840.1.113883.3.72 |
| Document Created: | June 20, 2012, 15:32:11 |
| 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 | 20120620153211 |
| Description | Codes | Time |
|---|---|---|
| Antihypertensive combinations | RxNorm: 858828 C0976596:Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet; |
February 4th, 2010 05:00 |
| ACE inhibitor or ARB | RxNorm: 314076 C0981555:Lisinopril 10 MG Oral Tablet; |
February 4th, 2010 05:00 |
| ACE inhibitor or ARB | RxNorm: 314076 C0981555:Lisinopril 10 MG Oral Tablet; |
July 20th, 2009 04:00 |
| Antiplatelet Therapy | RxNorm: 243670 C0783425:Aspirin 81 MG Oral Tablet; |
March 31st, 2010 04:00 |
| Antiplatelet Therapy | RxNorm: 243670 C0783425:Aspirin 81 MG Oral Tablet; |
July 14th, 2009 04:00 |
| Short acting beta 2 agonist | RxNorm: 630208 C1696556:Albuterol 0.83 MG/ML Inhalant Solution; |
July 14th, 2009 04:00 |
| Long acting inhaled beta 2 agonist | RxNorm: 318142 C2731895:60 ACTUAT Fluticasone propionate 0.115 MG/ACTUAT / salmeterol 0.021 MG/ACTUAT Metered Dose Inhaler; |
July 14th, 2009 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.; |
September 24th, 2010 04:00 |
| Encounter Office & Outpatient Consult | CPT: 99241 C0199299:Office 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 15 minutes face-to-face with the patient and/or family.; |
August 25th, 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.; |
May 10th, 2010 04:00 |
| Encounter Office & Outpatient Consult | CPT: 99241 C0199299:Office 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 15 minutes face-to-face with the patient and/or family.; |
March 31st, 2010 04:00 |
| Encounter Inpatient Discharge | CPT: 99238 C0374572:Hospital discharge day management; 30 minutes or less; |
July 20th, 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.; |
July 14th, 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; |
July 14th, 2009 04:00 | active |
| Coronary Artery Disease includes MI | ICD-9-CM: 410.90 ICD-10-CM: I21.3 SNOMED-CT: 57054005 C0155626:Acute myocardial infarction; |
July 14th, 2009 04:00 | inactive |
| Asthma Persistent | ICD-10-CM: J45.42 SNOMED-CT: 427295004 C1960047:Moderate persistent asthma; |
July 20th, 2009 04:00 | active |
| Asthma | ICD-9-CM: 493.92 ICD-10-CM: J45 SNOMED-CT: 195979001 C0340062:Hyperreactive airway disease; C0004096:Asthma; |
July 14th, 2009 04:00 | active |
| Myocardial Infarction | ICD-9-CM: 410.90 ICD-10-CM: I21.3 SNOMED-CT: 304914007 C0582803:Acute Q wave myocardial infarction; |
July 20th, 2009 04:00 | resolved |
| Asthma Daytime Symptoms Quantified | SNOMED-CT: 370202007 C1288256:Asthma causes daytime symptoms 1 to 2 times per month; |
August 25th, 2010 04:00 | |
| Asthma Nighttime Symptoms Quantified | SNOMED-CT: 370205009 C1288255:Asthma causes night symptoms 1 to 2 times per month (finding); |
August 25th, 2010 04:00 | |
| Asthma Daytime Symptoms Quantified | SNOMED-CT: 370202007 C1288256:Asthma causes daytime symptoms 1 to 2 times per month; |
July 14th, 2009 04:00 | |
| Asthma Nighttime Symptoms Quantified | SNOMED-CT: 370205009 C1288255:Asthma causes night symptoms 1 to 2 times per month (finding); |
July 14th, 2009 04:00 |
| Description | Codes | Time | Value |
|---|---|---|---|
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
September 24th, 2010 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
September 24th, 2010 04:00 | |
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
May 10th, 2010 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
May 10th, 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 | |
| BMI | SNOMED-CT: 60621009 LOINC: 39156-5 C1542867:Body mass index:Relative Density:Point in time:^Patient:Quantitative; |
September 24th, 2010 04:00 | |
| BMI | SNOMED-CT: 60621009 LOINC: 39156-5 C1542867:Body mass index:Relative Density:Point in time:^Patient:Quantitative; |
August 25th, 2010 04:00 | |
| BMI | SNOMED-CT: 60621009 LOINC: 39156-5 C1542867:Body mass index:Relative Density:Point in time:^Patient:Quantitative; |
May 10th, 2010 04:00 | |
| BMI | SNOMED-CT: 60621009 LOINC: 39156-5 C1542867:Body mass index:Relative Density:Point in time:^Patient:Quantitative; |
March 31st, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Asthma Symptom Assessment Tool | SNOMED-CT: 401011001 C1276011:Peak expiratory flow rate monitoring using diary; |
March 31st, 2010 04:00 |
| CABG | CPT: 33535 HCPCS: S2209 ICD-9-CM: 36.13 SNOMED-CT: 10326007 C0190233:Coronary artery bypass with autogenous graft, three grafts; |
July 14th, 2009 04:00 |
| Cardiac Surgery | SNOMED-CT: 10326007 CPT: 33535 C0371566:Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts; |
July 14th, 2009 04:00 |
| Description | Codes | Time | Value |
|---|---|---|---|
| LDL | CPT: 83721 LOINC: 2089-1 SNOMED-CT: 113079009 C0202117:Low density lipoprotein cholesterol measurement; |
May 10th, 2010 04:00 | |
| High Density Lipoprotein (HDL) | CPT: 83701 LOINC: 14646-4 SNOMED-CT: 28036006 C0392885:High density lipoprotein measurement; |
May 10th, 2010 04:00 | |
| Triglycerides | CPT: 84478 LOINC: 12951-0 SNOMED-CT: 14740000 C0202236:Triglycerides measurement; |
May 10th, 2010 04:00 | |
| Total Cholesterol | CPT: 82465 LOINC: 2093-3 SNOMED-CT: 121868005 C0546633:Cholesterol total measurement; |
May 10th, 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 24th, 2010 04:00 |
| Pneumococcal Vaccine all ages | CVX: 100 CPT: 90669 C2724348:Pneumococcal conjugate vaccine, 7 valent, for intramuscular use; |
September 24th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Tobacco Non-User | SNOMED-CT: 160618006 C0425311:Current non-smoker; |
March 31st, 2010 04:00 |