36 lines
1.5 KiB
Plaintext
36 lines
1.5 KiB
Plaintext
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
|
||
|