Correct all of the office visit csv files and rename per the new naming scheme.
Generate wiki text file output for all office visit files
This commit is contained in:
mish
parent
0b30c0d292
commit
a2fa042af5
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@ -61,22 +61,29 @@ Clinical Summaries Test Data
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{| border="1"|
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!colspan="10"|Medication List
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|----
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!scope="col"|RxNorm
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!scope="col"|RxNorm Code
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!scope="col"|Product
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!scope="col"|Generic Name
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!scope="col"|Brand Name
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!scope="col"|Strength
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!scope="col"|Dose
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!scope="col"|Route
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!scope="col"|Frequency
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!scope="col"|Date Started
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!scope="col"|Status
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|----
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|Product
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|Generic Name
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|Brand Name
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|Strength
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|Dose
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|Route
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|Frequency
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|Date Started
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|Status
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|205875
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|Medication
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|glyburide
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|Diabeta
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|2.5 mg
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|1 Tablet
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|PO
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|Q AM
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|07/20/2010
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|Active
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|----
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|}
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Code
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205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|07/20/2010|Active
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{| border="1"|
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!colspan="5"|Medication Allergy List
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@ -0,0 +1,143 @@
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Test Procedure for §170.304.h Clinical Summaries
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APPROVED (Pending) Version 1.0 July 21, 2010
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TD170.304.h.: Clinical summaries
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* indicates alternative standard code per certification criteria
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Clinical Summaries Test Data – Set #1|Office Visit #2 for Jonas Barnaby
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{| border="1"|
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!colspan="6"|Patient
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|----
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!scope="col"|Name
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!scope="col"|Date/Time of Birth
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!scope="col"|Gender
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!scope="col"|Identification Number
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!scope="col"|Identification Number Type
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!scope="col"|Address/Phone
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|----
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|Jonas Barnaby
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|07/14/1961 12:30:24
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|Male
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|969988999
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|Medical Record Number
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|478 Charles Street,<br>Williamsport,<br>Pennsylvania 17701<br>570-857-8593
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|----
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|}
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“Source” for all data for this patient: Marcus Welby, MD
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{| border="1"|
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!colspan="6"|Problem List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Condition
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|272.4
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|Hyperlipidemia
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|Active
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|02/20/2010
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|----
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code*
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Disorder
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|55822004
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|Hyperlipidemia
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|Active
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|02/20/2010
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|----
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|}
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{| border="1"|
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!colspan="10"|Medication List
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|----
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!scope="col"|RxNorm Code
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!scope="col"|Product
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!scope="col"|Generic Name
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!scope="col"|Brand Name
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!scope="col"|Strength
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!scope="col"|Dose
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!scope="col"|Route
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!scope="col"|Frequency
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!scope="col"|Date Started
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!scope="col"|Status
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|----
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|617314
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|Medication
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|atorvastatin calcium
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|Lipitor
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|10 mg
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|1 Tablet
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|PO
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|Q Day
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|02/20/2010
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|Active
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|----
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|}
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{| border="1"|
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!colspan="5"|Medication Allergy List
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code
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!scope="col"|Medication/Agent
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!scope="col"|Reaction
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!scope="col"|Date Recorded
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|----
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|Drug Allergy
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|293597001
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|Codeine
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|Hives
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|06/27/1996
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|----
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|Drug Allergy
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|294506009
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|Ampicillin
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|Diarrhea, nausea, vomiting
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|03/15/1994
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|----
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|}
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{| border="1"|
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!colspan="5"|Diagnostic Test Results
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|----
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!scope="col"|Type
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!scope="col"|LOINC Code
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!scope="col"|Test (Normal Range)
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!scope="col"|Result
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!scope="col"|Date Performed
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|----
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|Chemistry
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|14647-2
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|Total cholesterol (<200 mg/dl)
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|262 mg/dl
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|02/20/2010
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|----
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|Chemistry
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|14646-4
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|HDL cholesterol (?40 mg/dl)
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|78 mg/dl
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|02/20/2010
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|----
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|Chemistry
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|2089-1
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|LDL cholesterol (<100 mg/dl)
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|184 mg/dl
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|02/20/2010
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|----
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|Chemistry
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|14927-8
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|Triglycerides (<150 mg/dl)
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|177 mg/dl
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|02/20/2010
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|----
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@ -0,0 +1,36 @@
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Test Procedure for §170.304.h Clinical Summaries
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APPROVED (Pending) Version 1.0 July 21, 2010
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TD170.304.h.: Clinical summaries
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* indicates alternative standard code per certification criteria
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Clinical Summaries Test Data – Set #1|Office Visit #2 for Jonas Barnaby
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Patient
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Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
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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
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“Source” for all data for this patient: Marcus Welby, MD
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Problem List
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Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
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Condition|272.4|Hyperlipidemia|Active|02/20/2010
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Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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Disorder|55822004|Hyperlipidemia|Active|02/20/2010
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Medication List
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RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|02/20/2010|Active
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Medication Allergy List
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Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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Drug Allergy|293597001|Codeine|Hives|06/27/1996
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Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/15/1994
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Diagnostic Test Results
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Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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Chemistry|14647-2|Total cholesterol (<200 mg/dl)|262 mg/dl|02/20/2010
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Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|78 mg/dl|02/20/2010
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Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|184 mg/dl|02/20/2010
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Chemistry|14927-8|Triglycerides (<150 mg/dl)|177 mg/dl|02/20/2010
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@ -0,0 +1,125 @@
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Test Procedure for §170.304.h Clinical Summaries
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APPROVED (Pending) Version 1.0 July 21, 2010
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TD170.304.h.: Clinical summaries
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* indicates alternative standard code per certification criteria
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Clinical Summaries Test Data – Set #2|Office Visit #1 for Robert Flint
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{| border="1"|
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!colspan="6"|Patient
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|----
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!scope="col"|Name
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!scope="col"|Date/Time of Birth
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!scope="col"|Gender
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!scope="col"|Identification Number
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!scope="col"|Identification Number Type
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!scope="col"|Address/Phone
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|----
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|Robert Flint
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|04/18/1983 20:18:04
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|Male
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|9813624798
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|Medical Record Number
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|747 Market Street,<br>Morton,<br>Illinois 61550<br>309-365-8298
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|----
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|}
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“Source” for all data for this patient: Carl Roberts, MD
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{| border="1"|
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!colspan="6"|Problem List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Diagnosis
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|493.00
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|Asthma, unspecified
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|Active
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|07/19/2009
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|----
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code*
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Disorder
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|195967001
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|Asthma
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|Active
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|07/19/2009
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|----
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|}
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{| border="1"|
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!colspan="10"|Medication List
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|----
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!scope="col"|RxNorm Code
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!scope="col"|Product
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!scope="col"|Generic Name
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!scope="col"|Brand Name
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!scope="col"|Strength
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!scope="col"|Dose
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!scope="col"|Route
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!scope="col"|Frequency
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!scope="col"|Date Started
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!scope="col"|Status
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|----
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|206833
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|Medication
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|metaproterenol sulfate
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|Alupent Inhalation Aerosol
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|15 mg/ml
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|2 Puffs
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|Inhaled
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|Q4h
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|07/19/2009
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|Active
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|----
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|}
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{| border="1"|
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!colspan="5"|Medication Allergy List
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code
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!scope="col"|Medication/Agent
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!scope="col"|Reaction
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!scope="col"|Date Recorded
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|----
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|Drug Allergy
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|91936005
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|Penicillin
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|Rash and anaphylaxis
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|08/10/2008
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|----
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|Drug Allergy
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|293620004
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|Indomethacin
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|Nausea, vomiting, rash, dizziness, headache
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|03/25/2003
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|----
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|}
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{| border="1"|
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!colspan="5"|Diagnostic Test Results
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|----
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!scope="col"|Type
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!scope="col"|LOINC Code
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!scope="col"|Test (Normal Range)
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!scope="col"|Result
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!scope="col"|Date Performed
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|----
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|Imaging
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|24648-8
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|Chest X-ray, PA
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|Increased bronchial wall markings, patchy infiltrates
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|07/19/2009
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|----
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@ -0,0 +1,33 @@
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Test Procedure for §170.304.h Clinical Summaries
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APPROVED (Pending) Version 1.0 July 21, 2010
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TD170.304.h.: Clinical summaries
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* indicates alternative standard code per certification criteria
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Clinical Summaries Test Data – Set #2|Office Visit #1 for Robert Flint
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Patient
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Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
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Robert Flint|04/18/1983 20:18:04|Male|9813624798|Medical Record Number|747 Market Street,<br>Morton,<br>Illinois 61550<br>309-365-8298
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“Source” for all data for this patient: Carl Roberts, MD
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Problem List
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Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
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Diagnosis|493.00|Asthma, unspecified|Active|07/19/2009
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Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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Disorder|195967001|Asthma|Active|07/19/2009
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Medication List
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RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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206833|Medication|metaproterenol sulfate|Alupent Inhalation Aerosol|15 mg/ml|2 Puffs|Inhaled|Q4h|07/19/2009|Active
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Medication Allergy List
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Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|08/10/2008
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Drug Allergy|293620004|Indomethacin|Nausea, vomiting, rash, dizziness, headache|03/25/2003
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Diagnostic Test Results
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Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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Imaging|24648-8|Chest X-ray, PA|Increased bronchial wall markings, patchy infiltrates|07/19/2009
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@ -0,0 +1,133 @@
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Test Procedure for §170.304.h Clinical Summaries
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APPROVED (Pending) Version 1.0 July 21, 2010
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TD170.304.h.: Clinical summaries
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* indicates alternative standard code per certification criteria
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Clinical Summaries Test Data – Set #2|Office Visit #2 for Robert Flint
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{| border="1"|
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!colspan="6"|Patient
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|----
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!scope="col"|Name
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!scope="col"|Date/Time of Birth
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!scope="col"|Gender
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!scope="col"|Identification Number
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!scope="col"|Identification Number Type
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!scope="col"|Address/Phone
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|----
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|Robert Flint
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|04/18/1983 20:18:04
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|Male
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|9813624798
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|Medical Record Number
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|747 Market Street,<br>Morton,<br>Illinois 61550<br>309-365-8298
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|----
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|}
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“Source” for all data for this patient: Carl Roberts, MD
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{| border="1"|
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!colspan="6"|Problem List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
|
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Diagnosis
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|250.02
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|Diabetes Mellitus, Type 2
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|Active
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|03/10/2010
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|----
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code*
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Disorder
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|44054006
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|Diabetes Mellitus, Type 2
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|Active
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|03/10/2010
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|----
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|}
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{| border="1"|
|
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!colspan="10"|Medication List
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|----
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!scope="col"|RxNorm Code
|
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!scope="col"|Product
|
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!scope="col"|Generic Name
|
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!scope="col"|Brand Name
|
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!scope="col"|Strength
|
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!scope="col"|Dose
|
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!scope="col"|Route
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!scope="col"|Frequency
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!scope="col"|Date Started
|
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!scope="col"|Status
|
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|----
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|205875
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|Medication
|
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|glyburide
|
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|Diabeta
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|2.5 mg
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|1 Tablet
|
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|PO
|
||||
|Q AM
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||||
|03/10/2010
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|Active
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||||
|----
|
||||
|}
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|
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{| border="1"|
|
||||
!colspan="5"|Medication Allergy List
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code
|
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!scope="col"|Medication/Agent
|
||||
!scope="col"|Reaction
|
||||
!scope="col"|Date Recorded
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|----
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|Drug Allergy
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|91936005
|
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|Penicillin
|
||||
|Rash and anaphylaxis
|
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|08/10/2008
|
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|----
|
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|Drug Allergy
|
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|293620004
|
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|Indomethacin
|
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|Nausea, vomiting, rash, dizziness, headache
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|03/25/2003
|
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|----
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|}
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|
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{| border="1"|
|
||||
!colspan="5"|Diagnostic Test Results
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||||
|----
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||||
!scope="col"|Type
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||||
!scope="col"|LOINC Code
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||||
!scope="col"|Test (Normal Range)
|
||||
!scope="col"|Result
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||||
!scope="col"|Date Performed
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|----
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|Chemistry
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|14771-0
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|Fasting Blood Glucose (70–100 mg/dl)
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|150 mg/dl
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|03/10/2010
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|----
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|Imaging
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|24648-8
|
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|Chest X-ray, PA
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|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance
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|03/10/2010
|
||||
|----
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|}
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|
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@ -0,0 +1,35 @@
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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 #2|Office Visit #2 for Robert Flint
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
Robert Flint|04/18/1983 20:18:04|Male|9813624798|Medical Record Number|747 Market Street,<br>Morton,<br>Illinois 61550<br>309-365-8298
|
||||
|
||||
“Source” for all data for this patient: Carl Roberts, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|03/10/2010
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|44054006|Diabetes Mellitus, Type 2|Active|03/10/2010
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|03/10/2010|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|08/10/2008
|
||||
Drug Allergy|293620004|Indomethacin|Nausea, vomiting, rash, dizziness, headache|03/25/2003
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|150 mg/dl|03/10/2010
|
||||
Imaging|24648-8|Chest X-ray, PA|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance|03/10/2010
|
||||
|
||||
|
|
|
@ -0,0 +1,131 @@
|
|||
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 #1 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
|
||||
|486
|
||||
|Pneumonia
|
||||
|Active
|
||||
|07/02/2010
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code*
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Disorder
|
||||
|233604007
|
||||
|Pneumonia
|
||||
|Active
|
||||
|07/02/2010
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|308460
|
||||
|Medication
|
||||
|azithromycin
|
||||
|Azithromycin
|
||||
|250 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|QD
|
||||
|07/02/2010
|
||||
|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
|
||||
|Bilateral Pneumonia
|
||||
|07/02/2010
|
||||
|----
|
||||
|Cardiology
|
||||
|34534-8
|
||||
|Electrocardiogram
|
||||
|Sinus Tachycardia
|
||||
|07/02/2010
|
||||
|----
|
||||
|
|
@ -0,0 +1,34 @@
|
|||
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 #1 for Barbara Simpson
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|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
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|486|Pneumonia|Active|07/02/2010
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|233604007|Pneumonia|Active|07/02/2010
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
308460|Medication|azithromycin|Azithromycin|250 mg|1 Tablet|PO|QD|07/02/2010|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|06/10/2009
|
||||
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Imaging|42272-5|Chest X-ray, PA & Lateral|Bilateral Pneumonia|07/02/2010
|
||||
Cardiology|34534-8|Electrocardiogram|Sinus Tachycardia|07/02/2010
|
||||
|
|
|
@ -0,0 +1,148 @@
|
|||
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
|
||||
|----
|
||||
|
|
@ -0,0 +1,36 @@
|
|||
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
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|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
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|02/10/2010
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|02/10/2010
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|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
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|06/10/2009
|
||||
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|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
|
||||
|
|
|
@ -0,0 +1,144 @@
|
|||
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 #4|Office Visit #1 for Susan Ellerby
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Susan Ellerby
|
||||
|12/08/1963 21:54:24
|
||||
|Female
|
||||
|925377799
|
||||
|Medical Record Number
|
||||
|483 Powell Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-9475
|
||||
|----
|
||||
|}
|
||||
|
||||
“Source” for all data for this patient: Dorcas Wayne, 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
|
||||
|----
|
||||
|Condition
|
||||
|272.4
|
||||
|Hyperlipidemia
|
||||
|Active
|
||||
|07/06/2010
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code*
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Disorder
|
||||
|55822004
|
||||
|Hyperlipidemia
|
||||
|Active
|
||||
|07/06/2010
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|617314
|
||||
|Medication
|
||||
|atorvastatin calcium
|
||||
|Lipitor
|
||||
|10 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|Q Day
|
||||
|07/06/2010
|
||||
|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
|
||||
|05/22/1998
|
||||
|----
|
||||
|Drug Allergy
|
||||
|293597001
|
||||
|Codeine
|
||||
|Hives
|
||||
|02/17/1992
|
||||
|----
|
||||
|}
|
||||
|
||||
|
||||
{| 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
|
||||
|14647-2
|
||||
|Total cholesterol (<200 mg/dl)
|
||||
|279 mg/dl
|
||||
|07/06/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|14646-4
|
||||
|HDL cholesterol (?40 mg/dl)
|
||||
|89 mg/dl
|
||||
|07/06/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|2089-1
|
||||
|LDL cholesterol (<100 mg/dl)
|
||||
|190 mg/dl
|
||||
|07/06/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|14927-8
|
||||
|Triglycerides (<150 mg/dl)
|
||||
|187 mg/dl
|
||||
|07/06/2010
|
||||
|----
|
||||
|
|
@ -0,0 +1,37 @@
|
|||
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 #4|Office Visit #1 for Susan Ellerby
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
Susan Ellerby|12/08/1963 21:54:24|Female|925377799|Medical Record Number|483 Powell Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-9475
|
||||
|
||||
“Source” for all data for this patient: Dorcas Wayne, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Condition|272.4|Hyperlipidemia|Active|07/06/2010
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|55822004|Hyperlipidemia|Active|07/06/2010
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|07/06/2010|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|05/22/1998
|
||||
Drug Allergy|293597001|Codeine|Hives|02/17/1992
|
||||
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Chemistry|14647-2|Total cholesterol (<200 mg/dl)|279 mg/dl|07/06/2010
|
||||
Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|89 mg/dl|07/06/2010
|
||||
Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|190 mg/dl|07/06/2010
|
||||
Chemistry|14927-8|Triglycerides (<150 mg/dl)|187 mg/dl|07/06/2010
|
||||
|
|
|
@ -0,0 +1,142 @@
|
|||
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 #4|Office Visit #2 for Susan Ellerby
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Susan Ellerby
|
||||
|12/08/1963 21:54:24
|
||||
|Female
|
||||
|925377799
|
||||
|Medical Record Number
|
||||
|483 Powell Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-9475
|
||||
|----
|
||||
|}
|
||||
|
||||
“Source” for all data for this patient: Dorcas Wayne, 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
|
||||
|----
|
||||
|Symptom
|
||||
|401.9
|
||||
|Hypertension, Essential
|
||||
|Active
|
||||
|02/05/2010
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code*
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Disorder
|
||||
|59621000
|
||||
|Essential Hypertension
|
||||
|Active
|
||||
|02/05/2010
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|200801
|
||||
|Medication
|
||||
|furosemide
|
||||
|Lasix
|
||||
|20 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|BID
|
||||
|02/05/2010
|
||||
|Active
|
||||
|----
|
||||
|628958
|
||||
|Medication
|
||||
|potassium chloride
|
||||
|Klor-Con
|
||||
|10 mEq
|
||||
|1 Tablet
|
||||
|PO
|
||||
|BID
|
||||
|02/05/2010
|
||||
|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
|
||||
|05/22/1998
|
||||
|----
|
||||
|Drug Allergy
|
||||
|293597001
|
||||
|Codeine
|
||||
|Hives
|
||||
|02/17/1992
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|2823-3
|
||||
|Potassium (3.5–5.3 mg/dl)
|
||||
|4.5 mg/dl
|
||||
|02/05/2010
|
||||
|----
|
||||
|Imaging
|
||||
|42272-5
|
||||
|Chest X-ray, PA & Lateral
|
||||
|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance
|
||||
|02/05/2010
|
||||
|----
|
||||
|
|
@ -0,0 +1,35 @@
|
|||
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 #4|Office Visit #2 for Susan Ellerby
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
Susan Ellerby|12/08/1963 21:54:24|Female|925377799|Medical Record Number|483 Powell Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-9475
|
||||
|
||||
“Source” for all data for this patient: Dorcas Wayne, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Symptom|401.9|Hypertension, Essential|Active|02/05/2010
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|59621000|Essential Hypertension|Active|02/05/2010
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|02/05/2010|Active
|
||||
628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/05/2010|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|05/22/1998
|
||||
Drug Allergy|293597001|Codeine|Hives|02/17/1992
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.5 mg/dl|02/05/2010
|
||||
Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance|02/05/2010
|
||||
|
|
|
@ -0,0 +1,126 @@
|
|||
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 #5|Office Visit #1 for Johnathan Stone
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Johnathan Stone
|
||||
|11/12/1966 08:18:08
|
||||
|Male
|
||||
|988772587
|
||||
|Medical Record Number
|
||||
|937 Sutter Street<br>Aurora,<br>Colorado 80011<br>303-544-9988
|
||||
|----
|
||||
|}
|
||||
|
||||
“Source” for all data for this patient: Samuel Johnston, 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
|
||||
|07/17/2010
|
||||
|----
|
||||
|----
|
||||
!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
|
||||
|07/17/2010
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|205875
|
||||
|Medication
|
||||
|glyburide
|
||||
|Diabeta
|
||||
|2.5 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|Q AM
|
||||
|07/17/2010
|
||||
|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
|
||||
|294506009
|
||||
|Ampicillin
|
||||
|Diarrhea, nausea, vomiting
|
||||
|03/25/1997
|
||||
|----
|
||||
|Drug Allergy
|
||||
|91939003
|
||||
|Sulfonamides
|
||||
|Hives, photosensitivity
|
||||
|04/25/1989
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|LOINC
|
||||
|Fasting Blood Glucose (70–100 mg/dl)
|
||||
|120 mg/dl
|
||||
|07/17/2010
|
||||
|----
|
||||
|
|
@ -0,0 +1,33 @@
|
|||
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 #5|Office Visit #1 for Johnathan Stone
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
Johnathan Stone|11/12/1966 08:18:08|Male|988772587|Medical Record Number|937 Sutter Street<br>Aurora,<br>Colorado 80011<br>303-544-9988
|
||||
|
||||
“Source” for all data for this patient: Samuel Johnston, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|07/17/2010
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|44054006|Diabetes Mellitus, Type 2|Active|07/17/2010
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|07/17/2010|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/25/1997
|
||||
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1989
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Chemistry|14771-0|LOINC|Fasting Blood Glucose (70–100 mg/dl)|120 mg/dl|07/17/2010
|
||||
|
|
|
@ -0,0 +1,146 @@
|
|||
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 #5|Office Visit #2 for Johnathan Stone
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Johnathan Stone
|
||||
|11/12/1966 08:18:08
|
||||
|Male
|
||||
|988772587
|
||||
|Medical Record Number
|
||||
|937 Sutter Street<br>Aurora,<br>Colorado 80011<br>303-544-9988
|
||||
|----
|
||||
|}
|
||||
|
||||
“Source” for all data for this patient: Samuel Johnston, 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
|
||||
|----
|
||||
|Symptom
|
||||
|401.9
|
||||
|Hypertension, Essential
|
||||
|Active
|
||||
|01/15/2010
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code*
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Disorder
|
||||
|59621000
|
||||
|Essential Hypertension
|
||||
|Active
|
||||
|01/15/2010
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|200801
|
||||
|Medication
|
||||
|furosemide
|
||||
|Lasix
|
||||
|20 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|BID
|
||||
|01/15/2010
|
||||
|Active
|
||||
|----
|
||||
|628958
|
||||
|Medication
|
||||
|potassium chloride
|
||||
|Klor-Con
|
||||
|10 mEq
|
||||
|1 Tablet
|
||||
|PO
|
||||
|BID
|
||||
|01/15/2010
|
||||
|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
|
||||
|294506009
|
||||
|Ampicillin
|
||||
|Diarrhea, nausea, vomiting
|
||||
|03/25/1997
|
||||
|----
|
||||
|Drug Allergy
|
||||
|91939003
|
||||
|Sulfonamides
|
||||
|Hives, photosensitivity
|
||||
|04/25/1989
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|2823-3
|
||||
|Potassium (3.5–5.3 mg/dl)
|
||||
|4.5 mg/dl
|
||||
|01/15/2010
|
||||
|----
|
||||
|Imaging
|
||||
|42272-5
|
||||
|Chest X-ray, PA & Lateral
|
||||
|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance
|
||||
|01/15/2010
|
||||
|----
|
||||
|}
|
||||
|
||||
|
||||
|
||||
|
|
@ -0,0 +1,38 @@
|
|||
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 #5|Office Visit #2 for Johnathan Stone
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
Johnathan Stone|11/12/1966 08:18:08|Male|988772587|Medical Record Number|937 Sutter Street<br>Aurora,<br>Colorado 80011<br>303-544-9988
|
||||
|
||||
“Source” for all data for this patient: Samuel Johnston, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Symptom|401.9|Hypertension, Essential|Active|01/15/2010
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|59621000|Essential Hypertension|Active|01/15/2010
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|01/15/2010|Active
|
||||
628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|01/15/2010|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/25/1997
|
||||
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1989
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.5 mg/dl|01/15/2010
|
||||
Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance |01/15/2010
|
||||
|
||||
|
||||
|
||||
|
Loading…
Reference in New Issue