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 #4|Office Visit #1 for Susan Ellerby 

Patient 
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone 
Susan Ellerby|12/08/1963 21:54:24|Female|925377799|Medical Record Number|483 Powell Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-9475 

“Source” for all data for this patient: Dorcas Wayne, MD 

Problem List 
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed 
Condition|272.4|Hyperlipidemia|Active|07/06/2010 
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed 
Disorder|55822004|Hyperlipidemia|Active|07/06/2010 

Medication List 
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status 
617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|07/06/2010|Active 

Medication Allergy List 
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded 
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|05/22/1998 
Drug Allergy|293597001|Codeine|Hives|02/17/1992 


Diagnostic Test Results 
Type|LOINC Code|Test (Normal Range)|Result|Date Performed 
Chemistry|14647-2|Total cholesterol (<200 mg/dl)|279 mg/dl|07/06/2010 
Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|89 mg/dl|07/06/2010 
Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|190 mg/dl|07/06/2010 
Chemistry|14927-8|Triglycerides (<150 mg/dl)|187 mg/dl|07/06/2010