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[1021] | 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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| 7 |
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| 8 | Clinical Summaries Test Data Set #1 Office Visit #1 for Jonas Barnaby
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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 | Jonas Barnaby 07/14/1961 Male 969988999 Medical Record Number 478 Charles Street,
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| 13 | 12:30:24 Williamsport,
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| 14 | Pennsylvania 17701
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| 15 | 570-857-8593
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| 16 |
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| 17 | Source for all data for this patient: Marcus Welby, MD
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| 18 |
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| 19 | Problem List
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| 20 | Type ICD-9 Code Patient Problem Status Date Diagnosed
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| 21 | Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 07/20/2010
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| 22 |
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| 23 | Type SNOMED Code* Patient Problem Status Date Diagnosed
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| 24 | Disorder 44054006 Diabetes Mellitus, Type 2 Active 07/20/2010
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| 25 |
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| 26 | Medication List
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| 27 | RxNorm
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| 28 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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| 29 | Code
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| 30 | 205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 07/20/2010 Active
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| 31 |
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| 32 | Medication Allergy List
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| 33 | Type SNOMED Code Medication/Agent Reaction Date Recorded
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| 34 | Drug Allergy 293597001 Codeine Hives 06/27/1996
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| 35 | Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/15/1994
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| 36 |
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| 37 |
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| 38 | Diagnostic Test Results
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| 39 | Type LOINC Code Test (Normal Range) Result Date Performed
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| 40 | Chemistry 14771-0 Fasting Blood Glucose (70100 mg/dl) 178 mg/dl 07/20/2010
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