145 lines
2.4 KiB
Plaintext
145 lines
2.4 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 #4|Office Visit #1 for Susan Ellerby
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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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|Susan Ellerby
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|12/08/1963 21:54:24
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|Female
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|925377799
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|Medical Record Number
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|483 Powell Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-9475
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|----
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|}
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“Source” for all data for this patient: Dorcas Wayne, 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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|07/06/2010
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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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|07/06/2010
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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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|07/06/2010
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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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|91936005
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|Penicillin
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|Rash and anaphylaxis
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|05/22/1998
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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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|02/17/1992
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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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|279 mg/dl
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|07/06/2010
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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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|89 mg/dl
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|07/06/2010
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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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|190 mg/dl
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|07/06/2010
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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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|187 mg/dl
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|07/06/2010
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|----
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