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