| 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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