| 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 #2|Office Visit #2 for Robert Flint
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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 | 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
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| 13 |
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| 14 | Source for all data for this patient: Carl Roberts, 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 | Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|03/10/2010
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| 19 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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| 20 | Disorder|44054006|Diabetes Mellitus, Type 2|Active|03/10/2010
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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 | 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|03/10/2010|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|91936005|Penicillin|Rash and anaphylaxis|08/10/2008
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| 29 | Drug Allergy|293620004|Indomethacin|Nausea, vomiting, rash, dizziness, headache|03/25/2003
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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|14771-0|Fasting Blood Glucose (70100 mg/dl)|150 mg/dl|03/10/2010
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| 34 | 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
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| 35 |
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