1 | Test Procedure for §170.304.h Clinical Summaries
|
---|
2 | APPROVED (Pending) Version 1.0 July 21, 2010
|
---|
3 |
|
---|
4 | TD170.304.h.: Clinical summaries
|
---|
5 |
|
---|
6 | * indicates alternative standard code per certification criteria
|
---|
7 |
|
---|
8 | Clinical Summaries Test Data Set #4|Office Visit #2 for Susan Ellerby
|
---|
9 |
|
---|
10 | Patient
|
---|
11 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
---|
12 | 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
|
---|
13 |
|
---|
14 | Source for all data for this patient: Dorcas Wayne, MD
|
---|
15 |
|
---|
16 | Problem List
|
---|
17 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
---|
18 | Symptom|401.9|Hypertension, Essential|Active|02/05/2010
|
---|
19 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
---|
20 | Disorder|59621000|Essential Hypertension|Active|02/05/2010
|
---|
21 |
|
---|
22 | Medication List
|
---|
23 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
---|
24 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|02/05/2010|Active
|
---|
25 | 628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/05/2010|Active
|
---|
26 |
|
---|
27 | Medication Allergy List
|
---|
28 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
---|
29 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|05/22/1998
|
---|
30 | Drug Allergy|293597001|Codeine|Hives|02/17/1992
|
---|
31 |
|
---|
32 | Diagnostic Test Results
|
---|
33 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
---|
34 | Chemistry|2823-3|Potassium (3.55.3 mg/dl)|4.5 mg/dl|02/05/2010
|
---|
35 | Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance|02/05/2010
|
---|