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 (135–146 mg/dl) 138 mg/dl 02/24/2010 Chemistry 2823-3 Potassium (3.5–5.3 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 (135–146 mg/dl) 126 mg/dl 02/22/2010 Chemistry 2823-3 Potassium (3.5–5.3 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