143 lines
2.5 KiB
Plaintext
143 lines
2.5 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 #2 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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|Symptom
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|401.9
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|Hypertension, Essential
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|Active
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|02/05/2010
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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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|59621000
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|Essential Hypertension
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|Active
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|02/05/2010
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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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|200801
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|Medication
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|furosemide
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|Lasix
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|20 mg
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|1 Tablet
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|PO
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|BID
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|02/05/2010
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|Active
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|628958
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|Medication
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|potassium chloride
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|Klor-Con
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|10 mEq
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|1 Tablet
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|PO
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|BID
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|02/05/2010
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|Active
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|}
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{| border="1"|
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!colspan="5"|Medication Allergy List
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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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|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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|2823-3
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|Potassium (3.5–5.3 mg/dl)
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|4.5 mg/dl
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|02/05/2010
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|----
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|Imaging
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|42272-5
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|Chest X-ray, PA & Lateral
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|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance
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|02/05/2010
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|----
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