| Patient | Samantha Charles | ||
| Date of birth | June 12, 1978, 04:00:00 | Sex | Female |
| Race | White | Ethnicity | Not Hispanic or Latino |
| Contact info | Pirmary Home: 202 Burlington Rd. Bedford, MA 01730 Tel: +1-781-271-3000 |
Patient IDs | 4fe1ecb1a9ffcc03cd00022e Cypress |
| Document Id | HITSP_C32v2.5_Rev6_16Sections_Entries_MinimalErrors 2.16.840.1.113883.3.72 |
| Document Created: | June 20, 2012, 15:30:58 |
| 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 | 20120620153058 |
| Description | Codes | Time |
|---|---|---|
| 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; |
April 1st, 2010 04:00 |
| Second generation cephalosporins | RxNorm: 309097 C0975418:Cefuroxime 250 MG Oral Tablet; |
April 1st, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Encounter Inpatient Discharge | CPT: 99238 C0374572:Hospital discharge day management; 30 minutes or less; |
December 12th, 2010 05:00 |
| 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.; |
December 9th, 2010 05:00 |
| Prenatal Visit | ICD-10-CM: Z34.9 SNOMED-CT: 424619006 ICD-9-CM: V22.2 C0451636:Pregnant state, incidental; |
December 6th, 2010 05:00 |
| Prenatal Visit | ICD-10-CM: Z34.9 SNOMED-CT: 424619006 ICD-9-CM: V22.2 C0451636:Pregnant state, incidental; |
November 28th, 2010 05:00 |
| Prenatal Visit | ICD-10-CM: Z34.9 SNOMED-CT: 424619006 ICD-9-CM: V22.2 C0451636:Pregnant state, incidental; |
November 20th, 2010 05:00 |
| Prenatal Visit | ICD-10-CM: Z34.9 SNOMED-CT: 424619006 ICD-9-CM: V22.2 C0451636:Pregnant state, incidental; |
October 10th, 2010 04:00 |
| Prenatal Visit | ICD-10-CM: Z34.9 SNOMED-CT: 424619006 ICD-9-CM: V22.2 C0451636:Pregnant state, incidental; |
July 10th, 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 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 1st, 2010 04:00 |
| Description | Codes | Time | Status |
|---|---|---|---|
| Delivery Live Births-Diagnosis | SNOMED-CT: 169961004 ICD-9-CM: 65.621 ICD-10-CM: O30 C0032989:Multiple Pregnancy; |
December 10th, 2010 05:00 | active |
| asthma | ICD-9-CM: 493.92 ICD-10-CM: J45 SNOMED-CT: 195979001 C0340062:Hyperreactive airway disease; C0004096:Asthma; |
November 2nd, 2010 04:00 | active |
| Pregnancy | ICD-10-CM: O26.90 ICD-9-CM: V22.2 SNOMED-CT: 77386006 C2903762:Pregnancy related conditions, unspecified, unspecified trimester; |
May 10th, 2010 04:00 | active |
| Estimated date of conception | SNOMED-CT: 248986005 C0425966:Estimated date of conception; |
March 12th, 2010 05:00 | |
| Asthma Daytime Symptoms Quantified | SNOMED-CT: 370202007 C1288256:Asthma causes daytime symptoms 1 to 2 times per month; |
April 1st, 2010 04:00 | |
| Asthma Nighttime Symptoms Quantified | SNOMED-CT: 370205009 C1288255:Asthma causes night symptoms 1 to 2 times per month (finding); |
April 1st, 2010 04:00 |
| Description | Codes | Time | Value |
|---|---|---|---|
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
December 6th, 2010 05:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
December 6th, 2010 05:00 | |
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
November 28th, 2010 05:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
November 28th, 2010 05:00 | |
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
November 20th, 2010 05:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
November 20th, 2010 05:00 | |
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
October 10th, 2010 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
October 10th, 2010 04:00 | |
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
July 10th, 2010 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
July 10th, 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 | |
| BMI | SNOMED-CT: 60621009 LOINC: 39156-5 C1542867:Body mass index:Relative Density:Point in time:^Patient:Quantitative; |
April 1st, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Asthma Symptom Assessment Tool | SNOMED-CT: 401011001 C1276011:Peak expiratory flow rate monitoring using diary; |
April 1st, 2010 04:00 |
| Delivery Live Births-Procedure | CPT: 59410 SNOMED-CT: 169961004 C1384485:Normal delivery; There are two SNOMED codes for "normal delivery;" 48782003 is the other one |
December 10th, 2010 05:00 |
| Description | Codes | Time | Value |
|---|---|---|---|
| HIV Screening | CPT: 87536 LOINC: 9665-1 SNOMED-CT: 104332002 C0523323:HIV p24 antigen test; |
July 15th, 2010 04:00 | |
| Pregnancy Test | CPT: 84702 LOINC: 2119-6 C0364239:Choriogonadotropin:Substance Concentration:Point in time:Serum/Plasma:Quantitative; |
May 10th, 2010 04:00 | |
| Rh Status Mother | LOINC: 1314-4 C0482428:Rh immune globulin screen:Impression/interpretation of study:Point in time:Whole blood:Nominal; |
October 10th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Tobacco Non-User | SNOMED-CT: 160618006 C0425311:Current non-smoker; |
April 1st, 2010 04:00 |