TestProcedurefor170.304.iExchangeClinicalInformationandPatientSummaryRecord 
APPROVED(Pending)Version1.0July21,2010 

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 (70100 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 