| 1 | Test Procedure for §170.304.h Clinical Summaries
|
|---|
| 2 | APPROVED (Pending) Version 1.0 July 21, 2010
|
|---|
| 3 |
|
|---|
| 4 | TD170.304.h.: Clinical summaries
|
|---|
| 5 |
|
|---|
| 6 | * indicates alternative standard code per certification criteria
|
|---|
| 7 |
|
|---|
| 8 | Clinical Summaries Test Data Set #1|Office Visit #1 for Jonas Barnaby
|
|---|
| 9 |
|
|---|
| 10 | {| border="1"|
|
|---|
| 11 | !colspan="6"|Patient
|
|---|
| 12 | |----
|
|---|
| 13 | !scope="col"|Name
|
|---|
| 14 | !scope="col"|Date/Time of Birth
|
|---|
| 15 | !scope="col"|Gender
|
|---|
| 16 | !scope="col"|Identification Number
|
|---|
| 17 | !scope="col"|Identification Number Type
|
|---|
| 18 | !scope="col"|Address/Phone
|
|---|
| 19 | |----
|
|---|
| 20 | |Jonas Barnaby
|
|---|
| 21 | |07/14/1961 12:30:24
|
|---|
| 22 | |Male
|
|---|
| 23 | |969988999
|
|---|
| 24 | |Medical Record Number
|
|---|
| 25 | |478 Charles Street,<br>Williamsport,<br>Pennsylvania 17701<br>570-857-8593
|
|---|
| 26 | |----
|
|---|
| 27 | |}
|
|---|
| 28 |
|
|---|
| 29 | Source for all data for this patient: Marcus Welby, MD
|
|---|
| 30 |
|
|---|
| 31 | {| border="1"|
|
|---|
| 32 | !colspan="6"|Problem List
|
|---|
| 33 | |----
|
|---|
| 34 | !scope="col"|Type
|
|---|
| 35 | !scope="col"|ICD-9 Code
|
|---|
| 36 | !scope="col"|Patient Problem
|
|---|
| 37 | !scope="col"|Status
|
|---|
| 38 | !scope="col"|Date Diagnosed
|
|---|
| 39 | |----
|
|---|
| 40 | |Diagnosis
|
|---|
| 41 | |250.02
|
|---|
| 42 | |Diabetes Mellitus, Type 2
|
|---|
| 43 | |Active
|
|---|
| 44 | |07/20/2010
|
|---|
| 45 | |----
|
|---|
| 46 | |----
|
|---|
| 47 | !scope="col"|Type
|
|---|
| 48 | !scope="col"|SNOMED Code*
|
|---|
| 49 | !scope="col"|Patient Problem
|
|---|
| 50 | !scope="col"|Status
|
|---|
| 51 | !scope="col"|Date Diagnosed
|
|---|
| 52 | |----
|
|---|
| 53 | |Disorder
|
|---|
| 54 | |44054006
|
|---|
| 55 | |Diabetes Mellitus, Type 2
|
|---|
| 56 | |Active
|
|---|
| 57 | |07/20/2010
|
|---|
| 58 | |----
|
|---|
| 59 | |}
|
|---|
| 60 |
|
|---|
| 61 | {| border="1"|
|
|---|
| 62 | !colspan="10"|Medication List
|
|---|
| 63 | |----
|
|---|
| 64 | !scope="col"|RxNorm Code
|
|---|
| 65 | !scope="col"|Product
|
|---|
| 66 | !scope="col"|Generic Name
|
|---|
| 67 | !scope="col"|Brand Name
|
|---|
| 68 | !scope="col"|Strength
|
|---|
| 69 | !scope="col"|Dose
|
|---|
| 70 | !scope="col"|Route
|
|---|
| 71 | !scope="col"|Frequency
|
|---|
| 72 | !scope="col"|Date Started
|
|---|
| 73 | !scope="col"|Status
|
|---|
| 74 | |----
|
|---|
| 75 | |205875
|
|---|
| 76 | |Medication
|
|---|
| 77 | |glyburide
|
|---|
| 78 | |Diabeta
|
|---|
| 79 | |2.5 mg
|
|---|
| 80 | |1 Tablet
|
|---|
| 81 | |PO
|
|---|
| 82 | |Q AM
|
|---|
| 83 | |07/20/2010
|
|---|
| 84 | |Active
|
|---|
| 85 | |----
|
|---|
| 86 | |}
|
|---|
| 87 |
|
|---|
| 88 | {| border="1"|
|
|---|
| 89 | !colspan="5"|Medication Allergy List
|
|---|
| 90 | |----
|
|---|
| 91 | !scope="col"|Type
|
|---|
| 92 | !scope="col"|SNOMED Code
|
|---|
| 93 | !scope="col"|Medication/Agent
|
|---|
| 94 | !scope="col"|Reaction
|
|---|
| 95 | !scope="col"|Date Recorded
|
|---|
| 96 | |----
|
|---|
| 97 | |Drug Allergy
|
|---|
| 98 | |293597001
|
|---|
| 99 | |Codeine
|
|---|
| 100 | |Hives
|
|---|
| 101 | |06/27/1996
|
|---|
| 102 | |----
|
|---|
| 103 | |Drug Allergy
|
|---|
| 104 | |294506009
|
|---|
| 105 | |Ampicillin
|
|---|
| 106 | |Diarrhea, nausea, vomiting
|
|---|
| 107 | |03/15/1994
|
|---|
| 108 | |----
|
|---|
| 109 | |}
|
|---|
| 110 |
|
|---|
| 111 | {| border="1"|
|
|---|
| 112 | !colspan="5"|Diagnostic Test Results
|
|---|
| 113 | |----
|
|---|
| 114 | !scope="col"|Type
|
|---|
| 115 | !scope="col"|LOINC Code
|
|---|
| 116 | !scope="col"|Test (Normal Range)
|
|---|
| 117 | !scope="col"|Result
|
|---|
| 118 | !scope="col"|Date Performed
|
|---|
| 119 | |----
|
|---|
| 120 | |Chemistry
|
|---|
| 121 | |14771-0
|
|---|
| 122 | |Fasting Blood Glucose (70100 mg/dl)
|
|---|
| 123 | |178 mg/dl
|
|---|
| 124 | |07/20/2010
|
|---|
| 125 | |----
|
|---|