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 #2 for Jonas Barnaby
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9 |
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10 | Patient
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11 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
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12 | Jonas Barnaby|07/14/1961 12:30:24|Male|969988999|Medical Record Number|478 Charles Street,<br>Williamsport,<br>Pennsylvania 17701<br>570-857-8593
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13 |
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14 | Source for all data for this patient: Marcus Welby, MD
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15 |
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16 | Problem List
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17 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
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18 | Condition|272.4|Hyperlipidemia|Active|02/20/2010
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19 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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20 | Disorder|55822004|Hyperlipidemia|Active|02/20/2010
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21 |
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22 | Medication List
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23 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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24 | 617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|02/20/2010|Active
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25 |
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26 | Medication Allergy List
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27 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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28 | Drug Allergy|293597001|Codeine|Hives|06/27/1996
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29 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/15/1994
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30 |
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31 | Diagnostic Test Results
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32 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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33 | Chemistry|14647-2|Total cholesterol (<200 mg/dl)|262 mg/dl|02/20/2010
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34 | Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|78 mg/dl|02/20/2010
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35 | Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|184 mg/dl|02/20/2010
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36 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|177 mg/dl|02/20/2010
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