| 1 | Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary Record
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| 2 | APPROVED (Pending) Version 1.0 July 21, 2010
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| 3 |
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| 4 | Patient Summary Record Test Data Set #2
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| 5 |
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| 6 | Patient
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| 7 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
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| 8 | Ralph Johnson|06/28/1984|Male|9813466798|Medical Record Number|355 Elm Street
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| 9 | 13:20:10|Morton,
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| 10 | Illinois|61550
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| 11 | 309-377-8365
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| 12 |
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| 13 | Source for all data for this patient: Carl Roberts, MD
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| 14 |
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| 15 | Problem List
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| 16 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
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| 17 | Diagnosis|493.00|Asthma, unspecified|Active|12/22/2009
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| 18 | Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|08/10/2008
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| 19 |
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| 20 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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| 21 | Disorder|195967001|Asthma|Active|12/22/2009
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| 22 | Disorder|44054006|Diabetes Mellitus, Type 2|Active|08/10/2008
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| 23 |
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| 24 | Medication List
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| 25 | RxNorm
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| 26 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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| 27 | Code
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| 28 | Alupent
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| 29 | metaproterenol
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| 30 | 206833|Medication|Inhalation|15 mg/ml|2 Puffs|Inhaled|Q4h|12/22/2009|Active
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| 31 | sulfate
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| 32 | Aerosol
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| 33 | 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|08/10/2008|Active
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| 34 |
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| 35 | Medication Allergy List
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| 36 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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| 37 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|08/10/2008
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| 38 | Nausea, vomiting, rash,
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| 39 | Drug Allergy|293620004|Indomethacin|03/25/2003
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| 40 | dizziness, headache
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| 41 | Diagnostic Test Results
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| 42 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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| 43 | Increased bronchial wall
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| 44 | Imaging|24648-8|Chest X-ray, PA|02/16/2010
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| 45 | markings, patchy infiltrates
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| 46 | Chemistry|14771-0|Fasting Blood Glucose (70100 mg/dl)|70 mg/dl|12/22/2009
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| 47 | Hematology|26449-9|Eosinophil Count (1 3 %)|2%|12/22/2009
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| 48 | Imaging|24648-8|Chest X-ray, PA|Bronchial wall markings|12/22/2009
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