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wiki for Dave's file

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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 #1|Office Visit #1 for Jonas Barnaby
{| 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
|----
|Jonas Barnaby
|07/14/1961 12:30:24
|Male
|969988999
|Medical Record Number
|478 Charles Street,<br>Williamsport,<br>Pennsylvania 17701<br>570-857-8593
|----
|}
“Source” for all data for this patient: Marcus Welby, 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
|07/20/2010
|----
|----
!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
|07/20/2010
|----
|}
{| border="1"|
!colspan="10"|Medication List
|----
!scope="col"|RxNorm
|----
|
|Product
|Generic Name
|Brand Name
|Strength
|Dose
|Route
|Frequency
|Date Started
|Status
|----
|}
Code
205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|07/20/2010|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
|293597001
|Codeine
|Hives
|06/27/1996
|----
|Drug Allergy
|294506009
|Ampicillin
|Diarrhea, nausea, vomiting
|03/15/1994
|----
|}
{| 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
|----
|Chemistry
|14771-0
|Fasting Blood Glucose (70–100 mg/dl)
|178 mg/dl
|07/20/2010
|----