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 #5|Office Visit #1 for Johnathan Stone Patient Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone Johnathan Stone|11/12/1966 08:18:08|Male|988772587|Medical Record Number|937 Sutter Street
Aurora,
Colorado 80011
303-544-9988 “Source” for all data for this patient: Samuel Johnston, MD Problem List Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|07/17/2010 Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed Disorder|44054006|Diabetes Mellitus, Type 2|Active|07/17/2010 Medication List RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|07/17/2010|Active Medication Allergy List Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/25/1997 Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1989 Diagnostic Test Results Type|LOINC Code|Test (Normal Range)|Result|Date Performed Chemistry|14771-0|LOINC|Fasting Blood Glucose (70–100 mg/dl)|120 mg/dl|07/17/2010