1.8 KiB
1.8 KiB
| 1 | Test Procedure for §170.304.h Clinical Summaries |
|---|---|
| 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 #3|Office Visit #2 for Barbara Simpson |
| 6 | Patient |
| 7 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
| 8 | 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 |
| 9 | “Source” for all data for this patient: Robert James, MD |
| 10 | Problem List |
| 11 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
| 12 | Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|02/10/2010 |
| 13 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
| 14 | Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|02/10/2010 |
| 15 | Medication List |
| 16 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
| 17 | 836370|Medication|ipratropium bromide monohydrate|Atrovent Inhaler|18 mcg/puff|2 Puffs|Inhaled|QID|02/10/2010|Active |
| 18 | 630208|Medication|albuterol sulfate|Albuterol Inhaler|2.5 mg/3ml|2 Puffs|Inhaled|Q 4 hours as needed|02/10/2010|Active |
| 19 | Medication Allergy List |
| 20 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
| 21 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|06/10/2009 |
| 22 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988 |
| 23 | Diagnostic Test Results |
| 24 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
| 25 | Imaging|42272-5|Chest X-ray, PA & Lateral|Hyperinflated lungs with flattened diaphragm and central pulmonary artery enlargement|02/10/2010 |
| 26 | Hematology|718-7|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)|16 g/dl|02/10/2010 |
| 27 | Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|45%|02/10/2010 |