Cypress Certification Patient Test Record: Betty Nelson

Description	Codes	Time	Status	Results	Fields
Diagnosis, Active: Upper Respiratory Infection (Code List: 2.16.840.1.113883.3.464.1003.102.12.1022)	SNOMED-CT: 195708003 Recurrent upper respiratory tract infection (disorder) ICD-9-CM: 460 Acute nasopharyngitis [common cold] ICD-10-CM: J00 Acute nasopharyngitis [common cold]	January 30th, 2012 12:15 - February 15th, 2012 12:15	active
Diagnosis, Active: Depression diagnosis (Code List: 2.16.840.1.113883.3.600.145)	SNOMED-CT: 14183003 Chronic major depressive disorder, single episode (disorder) ICD-9-CM: 296.21 Major depressive affective disorder, single episode, mild ICD-10-CM: F32.0 Major depressive disorder, single episode, mild	January 30th, 2012 12:30 - March 30th, 2012 12:30	active
Diagnosis, Active: Persistent Asthma (Code List: 2.16.840.1.113883.3.464.1003.102.12.1023)	SNOMED-CT: 426656000 Severe persistent asthma (disorder) ICD-10-CM: J45.30 Mild persistent asthma, uncomplicated	April 30th, 2012 12:05 - present	active
Diagnosis, Active: Acute Pharyngitis (Code List: 2.16.840.1.113883.3.464.1003.102.12.1011)	ICD-9-CM: 034.0 Streptococcal sore throat SNOMED-CT: 1532007 Viral pharyngitis (disorder) ICD-10-CM: J02.8 Acute pharyngitis due to other specified organisms	April 30th, 2012 12:30 - May 30th, 2012 12:30	active

Description	Codes	Time	Status	Results	Fields
Encounter, Performed: Office Visit (Code List: 2.16.840.1.113883.3.464.1003.101.12.1001)	CPT: 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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. Typically, 10 minutes are spent face-to-face with the patient and/or family.	January 30th, 2012 12:00 - January 30th, 2012 13:00	performed
Encounter, Performed: Office Visit (Code List: 2.16.840.1.113883.3.464.1003.101.12.1001)	CPT: 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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. Typically, 10 minutes are spent face-to-face with the patient and/or family.	April 30th, 2012 12:00 - April 30th, 2012 13:00	performed

Description	Codes	Time	Status	Results	Fields
Medication, Dispensed: Preferred Asthma Therapy (Code List: 2.16.840.1.113883.3.464.1003.196.12.1212)	RxNorm: 1085805 240 ACTUAT Triamcinolone Acetonide 0.075 MG/ACTUAT Metered Dose Inhaler	April 30th, 2012 12:05 - April 30th, 2012 12:05	dispensed
Medication, Order: Antibiotic Medications (Code List: 2.16.840.1.113883.3.464.1003.196.12.1001)	RxNorm: 105152 Amoxicillin 60 MG/ML Oral Suspension	April 30th, 2012 12:40 - April 30th, 2012 12:40	ordered

Description	Codes	Time	Status	Results	Fields
Procedure, Performed: Influenza Vaccination (Code List: 2.16.840.1.113883.3.526.3.402)	SNOMED-CT: 442333005 Influenza A virus subtype H1N1 vaccination (procedure) CPT: 90653 Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use	January 30th, 2012 12:00 - January 30th, 2012 12:00	performed

Description	Codes	Time	Status	Results	Fields
Risk Category Assessment: Adolescent Depression Screening (Code List: 2.16.840.1.113883.3.600.2452)	LOINC: 73831-0 Adolescent depression screening assessment	January 30th, 2012 12:25 - January 30th, 2012 12:25		SNOMED-CT: 428171000124102 (Negative Depression Screening)

Description	Codes	Time	Status	Results	Fields
Intervention, Performed: Counseling for Nutrition (Code List: 2.16.840.1.113883.3.464.1003.195.12.1003)	SNOMED-CT: 11816003 Diet education (procedure) CPT: 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes	April 30th, 2012 12:30 - April 30th, 2012 12:45	performed

Description	Codes	Time	Status	Results	Fields
Laboratory Test, Result: Group A Streptococcus Test (Code List: 2.16.840.1.113883.3.464.1003.198.12.1012)	LOINC: 11268-0 Streptococcus pyogenes [Presence] in Throat by Organism specific culture	April 30th, 2012 12:00 - April 30th, 2012 12:00		positive
Laboratory Test, Result: Chlamydia Screening (Code List: 2.16.840.1.113883.3.464.1003.110.12.1052)	LOINC: 13217-5 Chlamydia trachomatis B Ab [Units/volume] in Serum	April 30th, 2012 12:05 - April 30th, 2012 12:05		LOINC: 13217-5 (Chlamydia Screening)
Laboratory Test, Order: Pap Test (Code List: 2.16.840.1.113883.3.464.1003.108.12.1017)	LOINC: 10524-7 Microscopic observation [Identifier] in Cervix by Cyto stain	April 30th, 2012 12:15 - April 30th, 2012 12:15	ordered	performed

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Laboratory Tests

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