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 #5|Office Visit #2 for Johnathan Stone

{| 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
|----
|Johnathan Stone
|11/12/1966 08:18:08
|Male
|988772587
|Medical Record Number
|937 Sutter Street<br>Aurora,<br>Colorado 80011<br>303-544-9988
|----
|}

“Source” for all data for this patient: Samuel Johnston, 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
|----
|Symptom
|401.9
|Hypertension, Essential
|Active
|01/15/2010
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|59621000
|Essential Hypertension
|Active
|01/15/2010
|----
|}

{| 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
|----
|200801
|Medication
|furosemide
|Lasix
|20 mg
|1 Tablet
|PO
|BID
|01/15/2010
|Active
|----
|628958
|Medication
|potassium chloride
|Klor-Con
|10 mEq
|1 Tablet
|PO
|BID
|01/15/2010
|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
|294506009
|Ampicillin
|Diarrhea, nausea, vomiting
|03/25/1997
|----
|Drug Allergy
|91939003
|Sulfonamides
|Hives, photosensitivity
|04/25/1989
|----
|}

{| 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
|2823-3
|Potassium (3.5–5.3 mg/dl)
|4.5 mg/dl
|01/15/2010
|----
|Imaging
|42272-5
|Chest X-ray, PA & Lateral
|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance 
|01/15/2010
|----
|}