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