Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary Record  
APPROVED (Pending) Version 1.0  July 21, 2010   

Patient Summary Record Test Data – Set #2 

Patient 
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone 
Ralph Johnson|06/28/1984|Male|9813466798|Medical Record Number|355 Elm Street 
13:20:10|Morton, 
Illinois|61550 
309-377-8365 

“Source” for all data for this patient: Carl Roberts, MD 

Problem List 
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed 
Diagnosis|493.00|Asthma, unspecified|Active|12/22/2009 
Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|08/10/2008 

Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed 
Disorder|195967001|Asthma|Active|12/22/2009 
Disorder|44054006|Diabetes Mellitus, Type 2|Active|08/10/2008 

Medication List 
RxNorm 
|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status 
Code 
Alupent 
metaproterenol 
206833|Medication|Inhalation|15 mg/ml|2 Puffs|Inhaled|Q4h|12/22/2009|Active 
sulfate 
Aerosol 
205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|08/10/2008|Active 

Medication Allergy List 
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded 
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|08/10/2008 
Nausea, vomiting, rash, 
Drug Allergy|293620004|Indomethacin|03/25/2003 
dizziness, headache 
Diagnostic Test Results 
Type|LOINC Code|Test (Normal Range)|Result|Date Performed 
Increased bronchial wall 
Imaging|24648-8|Chest X-ray, PA|02/16/2010 
markings, patchy infiltrates 
Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|70 mg/dl|12/22/2009 
Hematology|26449-9|Eosinophil Count (1 – 3 %)|2%|12/22/2009 
Imaging|24648-8|Chest X-ray, PA|Bronchial wall markings|12/22/2009