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 #3|Office Visit #2 for Barbara Simpson

{| 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
|----
|Barbara Simpson
|10/12/1956 19:47:01
|Female
|9688675266
|Medical Record Number
|996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534
|----
|}

“Source” for all data for this patient: Robert James, 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
|496.0
|Chronic Obstructive Pulmonary Disease
|Chronic
|02/10/2010
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|13645005
|Chronic Obstructive Lung Disease
|Chronic
|02/10/2010
|----
|}

{| 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
|----
|836370
|Medication
|ipratropium bromide monohydrate
|Atrovent Inhaler
|18 mcg/puff
|2 Puffs
|Inhaled
|QID
|02/10/2010
|Active
|----
|630208
|Medication
|albuterol sulfate
|Albuterol Inhaler
|2.5 mg/3ml
|2 Puffs
|Inhaled
|Q 4 hours as needed
|02/10/2010
|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
|06/10/2009
|----
|Drug Allergy
|91939003
|Sulfonamides
|Hives, photosensitivity
|04/25/1988
|----
|}

{| 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
|42272-5
|Chest X-ray, PA & Lateral
|Hyperinflated lungs with flattened diaphragm and central pulmonary artery enlargement
|02/10/2010
|----
|Hematology
|718-7
|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)
|16 g/dl
|02/10/2010
|----
|Hematology
|4544-3
|Hematocrit (male: 40-54% female: 36-48%)
|45%
|02/10/2010
|----