37 lines
1.5 KiB
Plaintext
37 lines
1.5 KiB
Plaintext
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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