wiki for Dave's file

2010-11-24 02:49:55 +00:00 · 2010-11-24 02:49:55 +00:00 · 67b837ea5c
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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
+|----