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 #2 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 
Symptom|401.9|Hypertension, Essential|Active|02/05/2010 
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed 
Disorder|59621000|Essential Hypertension|Active|02/05/2010 

Medication List 
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status 
200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|02/05/2010|Active 
628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/05/2010|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|2823-3|Potassium (3.5–5.3 mg/dl)|4.5 mg/dl|02/05/2010 
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