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 #3|Office Visit #1 for Barbara Simpson 

Patient 
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone 
Barbara Simpson|10/12/1956 19:47:01|Female|9688675266|Medical Record Number|996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534 

“Source” for all data for this patient: Robert James, MD 

Problem List 
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed 
Diagnosis|486|Pneumonia|Active|07/02/2010 
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed 
Disorder|233604007|Pneumonia|Active|07/02/2010 

Medication List 
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
308460|Medication|azithromycin|Azithromycin|250 mg|1 Tablet|PO|QD|07/02/2010|Active 

Medication Allergy List 
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded 
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|06/10/2009 
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988 

Diagnostic Test Results 
Type|LOINC Code|Test (Normal Range)|Result|Date Performed 
Imaging|42272-5|Chest X-ray, PA & Lateral|Bilateral Pneumonia|07/02/2010
Cardiology|34534-8|Electrocardiogram|Sinus Tachycardia|07/02/2010