| Patient | Greta Spears | ||
| Date of birth | February 1, 1953, 05:00:00 | 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 | 4fe1ed0fa9ffcc03cd001aec Cypress |
| Document Id | HITSP_C32v2.5_Rev6_16Sections_Entries_MinimalErrors 2.16.840.1.113883.3.72 |
| Document Created: | June 20, 2012, 15:32:31 |
| 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 | 20120620153231 |
| 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 4th, 2010 04:00 |
| Short acting beta 2 agonist | RxNorm: 630208 C1696556:Albuterol 0.83 MG/ML Inhalant Solution; |
April 4th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| 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.; |
December 4th, 2010 05:00 |
| 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.; |
September 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.; |
July 14th, 2010 04:00 |
| encounter ob/gyn | ICD-9-CM: V72.3 C1455986:Special investigations and examinations - Gynecological examination; |
June 12th, 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 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.; |
May 1st, 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.; |
April 4th, 2010 04:00 |
| Description | Codes | Time | Status |
|---|---|---|---|
| Asthma | ICD-9-CM: 493.92 ICD-10-CM: J45 SNOMED-CT: 195979001 C0340062:Hyperreactive airway disease; C0004096:Asthma; |
April 4th, 2010 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; |
December 4th, 2010 05:00 | active |
| Asthma Daytime Symptoms Quantified | SNOMED-CT: 370202007 C1288256:Asthma causes daytime symptoms 1 to 2 times per month; |
April 4th, 2010 04:00 | |
| Asthma Daytime Symptoms Quantified | SNOMED-CT: 370202007 C1288256:Asthma causes daytime symptoms 1 to 2 times per month; |
April 4th, 2010 04:00 |
| Description | Codes | Time | Value |
|---|---|---|---|
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
July 14th, 2010 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
July 14th, 2010 04:00 | |
| Systolic Blood Pressure | SNOMED-CT: 271649006 C0871470:Systolic Pressure; |
May 6th, 2010 04:00 | |
| Diastolic Blood Pressure | SNOMED-CT: 271650006 C0428883:Diastolic blood pressure; |
May 6th, 2010 04:00 | |
| BMI | SNOMED-CT: 60621009 LOINC: 39156-5 C1542867:Body mass index:Relative Density:Point in time:^Patient:Quantitative; |
July 14th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| tobacco use cessation counseling | SNOMED-CT: 384742004 CPT: 99406 C1692317:Smoking cessation assistance; |
May 1st, 2010 04:00 |
| Optic Nerve Head Evaluation | SNOMED-CT: 36228007 C0200149:Ophthalmic examination and evaluation; |
December 4th, 2010 05:00 |
| Description | Codes | Time | Value |
|---|---|---|---|
| Pap Test | ICD-9-CM: V72.32 ICD-10-CM: Z12.4 CPT: 88174 HCPCS: G0147 LOINC: 10524-7 SNOMED-CT: 440623000 C2585782:Microscopic examination of cervical Papanicolaou smear; |
June 12th, 2010 04:00 | |
| FOBT | CPT: 82274 SNOMED-CT: 252156002 LOINC: 2335-8 HCPCS: G0328 ICD-9-CM: V76.51 C0878742:Encounter for screening for malignant neoplasms of colon; |
July 14th, 2010 04:00 |
| Description | Codes | Time |
|---|---|---|
| Tobacco User | SNOMED-CT: 230062009 C0459846:Moderate cigarette smoker; |
May 1st, 2010 04:00 |