1 | Test Procedure for §170.304.h Clinical Summaries
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2 | APPROVED (Pending) Version 1.0 July 21, 2010
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3 |
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4 | TD170.304.h.: Clinical summaries
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5 |
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6 | * indicates alternative standard code per certification criteria
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8 | Clinical Summaries Test Data Set #5|Office Visit #2 for Johnathan Stone
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9 |
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10 | Patient
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11 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
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12 | 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
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13 |
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14 | Source for all data for this patient: Samuel Johnston, MD
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15 |
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16 | Problem List
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17 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
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18 | Symptom|401.9|Hypertension, Essential|Active|01/15/2010
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19 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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20 | Disorder|59621000|Essential Hypertension|Active|01/15/2010
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21 |
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22 | Medication List
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23 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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24 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|01/15/2010|Active
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25 | 628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|01/15/2010|Active
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26 |
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27 | Medication Allergy List
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28 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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29 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/25/1997
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30 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1989
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31 |
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32 | Diagnostic Test Results
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33 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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34 | Chemistry|2823-3|Potassium (3.55.3 mg/dl)|4.5 mg/dl|01/15/2010
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35 | Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance |01/15/2010
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