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<br>Aurora,<br>Colorado 80011<br>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