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 #2 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,
Fargo,
North Dakota 54102
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|496.0|Chronic Obstructive Pulmonary Disease|Chronic|02/10/2010
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|02/10/2010
Medication List
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
836370|Medication|ipratropium bromide monohydrate|Atrovent Inhaler|18 mcg/puff|2 Puffs|Inhaled|QID|02/10/2010|Active
630208|Medication|albuterol sulfate|Albuterol Inhaler|2.5 mg/3ml|2 Puffs|Inhaled|Q 4 hours as needed|02/10/2010|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|Hyperinflated lungs with flattened diaphragm and central pulmonary artery enlargement|02/10/2010
Hematology|718-7|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)|16 g/dl|02/10/2010
Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|45%|02/10/2010