Test Procedure for §170.304.h Clinical Summaries  
APPROVED (Pending) Version 1.0  July 21, 2010   

TD170.304.h.: Clinical summaries 

* indicates alternative standard code per certification criteria 

Clinical Summaries Test Data – Set #2|Office Visit #2 for Robert Flint 

Patient 
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone 
Robert Flint|04/18/1983 20:18:04|Male|9813624798|Medical Record Number|747 Market Street,<br>Morton,<br>Illinois 61550<br>309-365-8298 

“Source” for all data for this patient: Carl Roberts, MD 

Problem List 
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed 
Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|03/10/2010 
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed 
Disorder|44054006|Diabetes Mellitus, Type 2|Active|03/10/2010 

Medication List 
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status 
205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|03/10/2010|Active 

Medication Allergy List 
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded 
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|08/10/2008 
Drug Allergy|293620004|Indomethacin|Nausea, vomiting, rash, dizziness, headache|03/25/2003 

Diagnostic Test Results 
Type|LOINC Code|Test (Normal Range)|Result|Date Performed 
Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|150 mg/dl|03/10/2010 
Imaging|24648-8|Chest X-ray, PA|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance|03/10/2010