TD170.306.f.: Exchange clinical information and patient summary record 

* indicates alternative standard code per certification criteria 

Patient Summary Record Test Data  Set #1 

Patient 
        Name              Date/Time of Birth           Gender         Identification Number        Identification Number Type               Address/Phone 
Ann Toliver                07/16/1950               Female             989285998                   Medical Record Number                 353 Wine Street 
                          14:15:12                                                                                                      Flint, 
                                                                                                                                        Michigan  48503 
                                                                                                                                       810-673-8378 

Source for all data for this patient: Fatima Goyal, MD 

Problem List 
        Type                  ICD-9 Code                                Patient Problem                                Status               Date Diagnosed 
Diagnosis               428.0                      Congestive Heart Failure                                       Active                 02/22/2010 
Diagnosis               410.90                     Acute Myocardial Infarction                                   Resolved                09/16/2007 

        Type               SNOMED Code*                                 Patient Problem                                Status               Date Diagnosed 
Disorder                 42343007                   Congestive Heart Failure                                      Active                 02/22/2010 
Disorder                 57054005                    Acute Myocardial Infarction                                 Resolved                09/16/2007 

Medication List 
  RxNorm 
                    Product         Generic Name         Brand Name         Strength        Dose         Route      Frequency        Date Started        Status 
    Code 
201372            Medication       captopril             Capoten            25 mg        Tablet          PO         TID              02/25/2010         Active 
200820            Medication       spironolactone       Aldactone           25 mg         Tablet         PO         QID               02/25/2010        Active 
309888            Medication        digoxin              Lanoxin             125 mcg      Tablet         PO         QD                02/25/2010        Active 
                                   potassium 
628958            Medication                            Klor-Con             10 mEq       1 Tablet       PO         BID               02/25/2010        Active 
                                   chloride 
198039            Medication        nitroglycerin        Nitroglycerin       400 mcg      1 Tablet       SL         As needed         09/20/2007        Active 

Medication Allergy List 
  Type                        SNOMED Code                          Medication/Agent                         Reaction                     Date Recorded 
Drug Allergy                  293586001                              Aspirin                              Wheezing                            03/02/2007 
Drug Allergy                  294506009                              Ampicillin                           Diarrhea, nausea, vomiting          04/25/1994 

Diagnostic Test Results 
         Type                  LOINC Code                         Test (Normal Range)                                 Result                     Date Performed 
                                                                                                         Enlarged cardiac silhouette, 
Imaging                    24648-8                     Chest X-ray, PA                                                                       02/24/2010 
                                                                                                         lung fields clear 
Chemistry                  2951-2                     Sodium (135146 mg/dl)                              138 mg/dl                          02/24/2010 
Chemistry                  2823-3                     Potassium (3.55.3 mg/dl)                           4.3 mg/dl                          02/24/2010 
Chemistry                 2075-0                      Chloride (95-107 mEq/L)                             98 mEq/L                            02/24/2010 
                                                                                                         Enlarged cardiac silhouette, 
Imaging                    24648-8                     Chest X-ray, PA                                   horizontal lines in the periphery   02/22/2010 
                                                                                                         of lower posterior lung fields 
Chemistry                 2951-2                      Sodium (135146 mg/dl)                              126 mg/dl                          02/22/2010 
Chemistry                 2823-3                      Potassium (3.55.3 mg/dl)                           3.0 mg/dl                          02/22/2010 
Chemistry                 2075-0                      Chloride (95-107 mEq/L)                             94 mEq/L                            02/22/2010 

Procedure List 
         Type                   ICD-9 Code                               Procedure                                     Status                    Date Performed 
Cardiac                    00.66                       Percutaneous transluminal coronary angioplasty       Completed                         09/17/2007 
Cardiac                   37.21                       Cardiac catheterization                                Completed                        10/01/2006 

         Type                   CPT Code*                                Procedure                                     Status                   Date Performed 
Cardiac                     92982                      Percutaneous transluminal coronary angioplasty       Completed                         09/17/2007 
Cardiac                    93501                      Cardiac catheterization                                Completed                        10/01/2006 
