Test Procedure for §170.304.h Clinical Summaries  APPROVED (Pending) Version 1.0  July 21, 2010   TD170.304.h.: Clinical summaries * indicates alternative standard code per certification criteria Clinical Summaries Test Data – Set #2|Office Visit #2 for Robert Flint {| border="1"| !colspan="6"|Patient |---- !scope="col"|Name !scope="col"|Date/Time of Birth !scope="col"|Gender !scope="col"|Identification Number !scope="col"|Identification Number Type !scope="col"|Address/Phone |---- |Robert Flint |04/18/1983 20:18:04 |Male |9813624798 |Medical Record Number |747 Market Street,
Morton,
Illinois 61550
309-365-8298 |---- |} “Source” for all data for this patient: Carl Roberts, MD {| border="1"| !colspan="6"|Problem List |---- !scope="col"|Type !scope="col"|ICD-9 Code !scope="col"|Patient Problem !scope="col"|Status !scope="col"|Date Diagnosed |---- |Diagnosis |250.02 |Diabetes Mellitus, Type 2 |Active |03/10/2010 |---- |---- !scope="col"|Type !scope="col"|SNOMED Code* !scope="col"|Patient Problem !scope="col"|Status !scope="col"|Date Diagnosed |---- |Disorder |44054006 |Diabetes Mellitus, Type 2 |Active |03/10/2010 |---- |} {| border="1"| !colspan="10"|Medication List |---- !scope="col"|RxNorm Code !scope="col"|Product !scope="col"|Generic Name !scope="col"|Brand Name !scope="col"|Strength !scope="col"|Dose !scope="col"|Route !scope="col"|Frequency !scope="col"|Date Started !scope="col"|Status |---- |205875 |Medication |glyburide |Diabeta |2.5 mg |1 Tablet |PO |Q AM |03/10/2010 |Active |---- |} {| border="1"| !colspan="5"|Medication Allergy List |---- !scope="col"|Type !scope="col"|SNOMED Code !scope="col"|Medication/Agent !scope="col"|Reaction !scope="col"|Date Recorded |---- |Drug Allergy |91936005 |Penicillin |Rash and anaphylaxis |08/10/2008 |---- |Drug Allergy |293620004 |Indomethacin |Nausea, vomiting, rash, dizziness, headache |03/25/2003 |---- |} {| border="1"| !colspan="5"|Diagnostic Test Results |---- !scope="col"|Type !scope="col"|LOINC Code !scope="col"|Test (Normal Range) !scope="col"|Result !scope="col"|Date Performed |---- |Chemistry |14771-0 |Fasting Blood Glucose (70–100 mg/dl) |150 mg/dl |03/10/2010 |---- |Imaging |24648-8 |Chest X-ray, PA |The heart outline is normal and the hilar and mediastinal vessels are of normal appearance |03/10/2010 |---- |}