1.4 KiB
1.4 KiB
1 | Test Procedure for §170.304.h Clinical Summaries |
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2 | APPROVED (Pending) Version 1.0 July 21, 2010 |
3 | TD170.304.h.: Clinical summaries |
4 | * indicates alternative standard code per certification criteria |
5 | Clinical Summaries Test Data – Set #2|Office Visit #1 for Robert Flint |
6 | Patient |
7 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
8 | 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 |
9 | “Source” for all data for this patient: Carl Roberts, MD |
10 | Problem List |
11 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
12 | Diagnosis|493.00|Asthma, unspecified|Active|07/19/2009 |
13 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
14 | Disorder|195967001|Asthma|Active|07/19/2009 |
15 | Medication List |
16 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
17 | 206833|Medication|metaproterenol sulfate|Alupent Inhalation Aerosol|15 mg/ml|2 Puffs|Inhaled|Q4h|07/19/2009|Active |
18 | Medication Allergy List |
19 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
20 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|08/10/2008 |
21 | Drug Allergy|293620004|Indomethacin|Nausea, vomiting, rash, dizziness, headache|03/25/2003 |
22 | Diagnostic Test Results |
23 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
24 | Imaging|24648-8|Chest X-ray, PA|Increased bronchial wall markings, patchy infiltrates|07/19/2009 |