TD170.306.f.: Exchange clinical information and patient summary record

* indicates alternative standard code per certification criteria

Patient Summary Record Test Data – Set #1

{| 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
|----
|Ann Toliver
|07/16/1950<br>14:15:12
|Female
|989285998
|Medical Record Number
|353 Wine Street <br>Flint, <br>Michigan 48503 <br> 810-673-8378
|----
|}

“Source” for all data for this patient: Fatima Goyal, 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
|428.0
|Congestive Heart Failure
|Active
|02/22/2010
|----
|Diagnosis
|410.90
|Acute Myocardial Infarction
|Resolved
|09/16/2007
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|42343007
|Congestive Heart Failure
|Active
|02/22/2010
|----
|Disorder
|57054005
|Acute Myocardial Infarction
|Resolved
|09/16/2007
|----
|}

{| 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
|----
|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
|----
|628958
|Medication
|potassium chloride
|Klor-Con
|10 mEq
|1 Tablet
|PO
|BID
|02/25/2010
|Active
|----
|198039
|Medication
|nitroglycerin
|Nitroglycerin
|400 mcg
|1 Tablet
|SL
|As needed
|09/20/2007
|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
|293586001
|Aspirin
|Wheezing
|03/02/2007
|----
|Drug Allergy
|294506009
|Ampicillin
|Diarrhea, nausea, vomiting
|04/25/1994
|----
|}

{| 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
|Enlarged cardiac silhouette, <br>lung fields clear 
|02/24/2010
|----
|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
|----
|Imaging
|24648-8
|Chest X-ray, PA
|Enlarged cardiac silhouette, <br>horizontal lines in the periphery<br>of lower posterior lung fields 
|02/22/2010
|----
|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
|----
|}

{| border="1"|
!colspan="5"|Procedure List
|----
!scope="col"|Type
!scope="col"|ICD-9 Code
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Cardiac
|00.66
|Percutaneous transluminal coronary angioplasty
|Completed
|09/17/2007
|----
|Cardiac
|37.21
|Cardiac catheterization
|Completed
|10/01/2006
|----
|----
!scope="col"|Type
!scope="col"|CPT Code*
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Cardiac
|92982
|Percutaneous transluminal coronary angioplasty
|Completed
|09/17/2007
|----
|Cardiac
|93501
|Cardiac catheterization
|Completed
|10/01/2006
|----