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

{| 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
|----
|Ralph Johnson
|06/28/1984 13:20:10
|Male
|9813466798
|Medical Record Number
|355 Elm Street<br>Morton,<br>Illinois 61550<br>309-377-8365
|----
|}

“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
|493.00
|Asthma, unspecified
|Active
|12/22/2009
|----
|Diagnosis
|250.02
|Diabetes Mellitus, Type 2
|Active
|08/10/2008
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|195967001
|Asthma
|Active
|12/22/2009
|----
|Disorder
|44054006
|Diabetes Mellitus, Type 2
|Active
|08/10/2008
|----
|}

{| 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
|----
|206833
|Medication
|metaproternol sulfate
|Alupent Inhalation Aerosol
|15 mg/ml
|2 Puffs
|Inhaled
|Q4h
|12/22/2009
|Active
|----
|205875
|Medication
|glyburide
|Diabeta
|2.5 mg
|1 Tablet
|PO
|Q AM
|08/10/2008
|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,<br>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
|----
|Imaging
|24648-8
|Chest X-ray, PA
|Increased bronchial wall<br>markings, patchy infiltrates
|02/16/2010
|----
|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
|----