38 lines
1.5 KiB
Plaintext
38 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 #4|Office Visit #1 for Susan Ellerby
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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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Susan Ellerby|12/08/1963 21:54:24|Female|925377799|Medical Record Number|483 Powell Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-9475
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“Source” for all data for this patient: Dorcas Wayne, 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|07/06/2010
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Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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Disorder|55822004|Hyperlipidemia|Active|07/06/2010
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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|07/06/2010|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|91936005|Penicillin|Rash and anaphylaxis|05/22/1998
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Drug Allergy|293597001|Codeine|Hives|02/17/1992
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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)|279 mg/dl|07/06/2010
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Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|89 mg/dl|07/06/2010
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Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|190 mg/dl|07/06/2010
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Chemistry|14927-8|Triglycerides (<150 mg/dl)|187 mg/dl|07/06/2010
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